Provider Demographics
NPI:1104884956
Name:POTYONDY, LOUIS DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:DAVID
Last Name:POTYONDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5209
Mailing Address - Country:US
Mailing Address - Phone:229-589-2588
Mailing Address - Fax:
Practice Address - Street 1:801 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5209
Practice Address - Country:US
Practice Address - Phone:229-589-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057743208200000X
WAMD 60288108208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA814916866AMedicaid
FL001281100Medicaid
GA1508824293OtherMEDICARE PRACTICE NPI
GAI52841Medicare UPIN
FLCL413ZMedicare UPIN
FL001281100Medicaid
GA814916866AMedicaid