Provider Demographics
NPI:1396066874
Name:POTTANAT, ROGER (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:POTTANAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:169 LIBBEY INDUSTRIAL PKWY
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-3101
Mailing Address - Country:US
Mailing Address - Phone:781-551-0999
Mailing Address - Fax:781-551-3396
Practice Address - Street 1:169 LIBBEY INDUSTRIAL PKWY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3101
Practice Address - Country:US
Practice Address - Phone:781-551-0999
Practice Address - Fax:781-551-3396
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2458672084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry