Provider Demographics
NPI:1588748818
Name:POTEGAL, MICHAEL J (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:POTEGAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:420 DELAWARE STREET SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-7466
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE STREET SE
Practice Address - Street 2:PWB FOURTH FLOOR, ROOM 4-100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-625-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4310103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1029892OtherPREFERRED ONE
MN163A1POOtherBLUE CROSS BLUE SHIELD
MN1497309OtherARAZ
SD7777470Medicaid
MN140910OtherUCARE
ND10387Medicaid
MNHP40584OtherHEALTH PARTNERS
MT0492031Medicaid