Provider Demographics
NPI:1316140650
Name:POTTENGER, LOWELL KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:LOWELL
Middle Name:KENNETH
Last Name:POTTENGER
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:PO BOX 2486
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2486
Mailing Address - Country:US
Mailing Address - Phone:417-781-4090
Mailing Address - Fax:414-782-1601
Practice Address - Street 1:4400 EDEN HALL LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64803
Practice Address - Country:US
Practice Address - Phone:417-781-4090
Practice Address - Fax:414-782-1601
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO307162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS04936673136Medicaid
MO200600807Medicaid
MO200600807Medicaid
MO002010457Medicare ID - Type Unspecified
OKG 011301045Medicare ID - Type Unspecified
MOMA2319004Medicare UPIN