Provider Demographics
NPI:1124814116
Name:POTACZALA, KAMIL
Entity type:Individual
Prefix:
First Name:KAMIL
Middle Name:
Last Name:POTACZALA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W EDGE WAY APT 4301
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-5873
Mailing Address - Country:US
Mailing Address - Phone:646-382-3201
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9274
Practice Address - Country:US
Practice Address - Phone:804-765-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program