Provider Demographics
NPI:1093844292
Name:JEROME R POTOZKIN MD, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JEROME R POTOZKIN MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:POTOZKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-838-4900
Mailing Address - Street 1:600 SAN RAMON VALLEY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4014
Mailing Address - Country:US
Mailing Address - Phone:925-385-8980
Mailing Address - Fax:925-838-4920
Practice Address - Street 1:600 SAN RAMON VALLEY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4014
Practice Address - Country:US
Practice Address - Phone:925-385-8980
Practice Address - Fax:925-838-4920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73505207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF53323Medicare UPIN