Provider Demographics
NPI:1194722652
Name:POTE, DOUGLAS ALLYN (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ALLYN
Last Name:POTE
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 1:636 S MONTE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:GLADE SPRING
Mailing Address - State:VA
Mailing Address - Zip Code:24340-2712
Mailing Address - Country:US
Mailing Address - Phone:276-429-5163
Mailing Address - Fax:276-429-5515
Practice Address - Street 1:636 S MONTE VISTA DR
Practice Address - Street 2:
Practice Address - City:GLADE SPRING
Practice Address - State:VA
Practice Address - Zip Code:24340-2712
Practice Address - Country:US
Practice Address - Phone:276-429-5163
Practice Address - Fax:276-429-5515
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01372202OtherRR MEDICARE
VA610722601OtherDEPT OF LABOR
VA007610131Medicaid
VA240748OtherANTHEM
VA1194722652Medicaid
VAVVC459Medicare PIN
VA1194722652Medicaid
VA610722601OtherDEPT OF LABOR