Provider Demographics
NPI:1548526601
Name:POTTER, OLIVIA LAUREN (DO)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LAUREN
Last Name:POTTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 MAPLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2749
Mailing Address - Country:US
Mailing Address - Phone:716-636-5437
Mailing Address - Fax:
Practice Address - Street 1:1800 MAPLE RD STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2749
Practice Address - Country:US
Practice Address - Phone:716-636-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT7005208000000X
FLOS13209208000000X
NY323941208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014809000Medicaid
FL014809000Medicaid