Provider Demographics
NPI:1194751800
Name:POTTERS, MARTIN D (PA)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:D
Last Name:POTTERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 616788
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32816-6788
Mailing Address - Country:US
Mailing Address - Phone:407-253-3537
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:14075 S TOWN LOOP BLVD.
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837
Practice Address - Country:US
Practice Address - Phone:407-438-5858
Practice Address - Fax:407-438-7172
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100906363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291961300Medicaid
FL291961300Medicaid