Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VX0000X | Obstetrician | 01043236 | IN |
NPI | 1427094911 |
---|---|
Provider Name | Victoria L Potoczak |
First Address | Terre Haute, IN 47802-5543 |
Second Address | Terre Haute, IN 47802-5543 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2006 |
Last Update Date | 10/10/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000093386 | BLUE SHIELD (01) | IN |
200157540 | (05) | IN |
G21970 | (02) | IN |