Basic Information
| Provider Information | |||||||||
| NPI: | 1780875799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTTORFF | ||||||||
| FirstName: | CELESTE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 E CAMELBACK RD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850163911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022411671 | ||||||||
| FaxNumber: | 6022746181 | ||||||||
| Practice Location | |||||||||
| Address1: | 1661 E CAMELBACK RD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850163911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022411671 | ||||||||
| FaxNumber: | 6022746181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | R1087 | AZ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 005675 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 623283 | 05 | AZ | MEDICAID |