Basic Information
| Provider Information | |||||||||
| NPI: | 1700861465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015795400 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 HALL ST | ||||||||
| Address2: | |||||||||
| City: | WIGGINS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395772110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019284412 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 23577 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD024152E | PA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 50000729 | 01 | CAP BLUE CROSS | OTHER | 05706756 | 05 | MS | MEDICAID | 0008570430005 | 05 | PA | MEDICAID | 151890 | 01 | HIGHMARK BLUE SHIELD | OTHER |