Provider Demographics
NPI:1215165022
Name:POTWIN, STACY (OD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:POTWIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7171 W GUNNISON ST
Mailing Address - Street 2:APT 12M
Mailing Address - City:HARWOOD HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60706-3892
Mailing Address - Country:US
Mailing Address - Phone:312-515-7486
Mailing Address - Fax:
Practice Address - Street 1:1622 COMMONS DR
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2531
Practice Address - Country:US
Practice Address - Phone:630-232-8798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2010-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010321152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist