Provider Demographics
NPI:1992770887
Name:POTTS, GREGORY A (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:POTTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 E 5TH ST
Mailing Address - Street 2:SUITE 328
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3135
Mailing Address - Country:US
Mailing Address - Phone:636-239-1101
Mailing Address - Fax:636-239-0250
Practice Address - Street 1:851 E 5TH ST
Practice Address - Street 2:SUITE 328
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3135
Practice Address - Country:US
Practice Address - Phone:636-239-1101
Practice Address - Fax:636-239-0250
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR7F05207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1992770887Medicaid
MO160059505OtherRAILROAD MEDICARE
MO160059505OtherRAILROAD MEDICARE
MO143090003Medicare PIN
MO1992770887Medicaid