Provider Demographics
NPI:1063919793
Name:POTTER, BENJAMIN (DPM)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3868
Mailing Address - Country:US
Mailing Address - Phone:423-245-3161
Mailing Address - Fax:
Practice Address - Street 1:430 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3868
Practice Address - Country:US
Practice Address - Phone:423-245-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL135.001005213ES0103X
TN905213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery