Provider Demographics
NPI:1992776884
Name:POTTER, MARK BLAINE (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BLAINE
Last Name:POTTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 GRANBURG CIR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-3033
Mailing Address - Country:US
Mailing Address - Phone:210-826-1308
Mailing Address - Fax:
Practice Address - Street 1:1112 6TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-272-8664
Practice Address - Fax:253-627-7880
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002013A207RG0100X
WAOP60322613207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology