Basic Information
| Provider Information | |||||||||
| NPI: | 1083657183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTOMSKI | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO CMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 E NEW HAVEN AVE STE 11 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217244545 | ||||||||
| FaxNumber: | 3217284168 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 E NEW HAVEN AVE | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217244545 | ||||||||
| FaxNumber: | 3217284168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | OS4425 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 067596200 | 05 | FL | MEDICAID |