Basic Information
| Provider Information | |||||||||
| NPI: | 1811196819 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTASH | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 695 S BROADWAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802094003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038996900 | ||||||||
| FaxNumber: | 3038996999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 06/28/2017 | ||||||||
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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 | 207ZP0102X | R8153 | IA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | DR.0051034 | 01 | CO | CO LICENSE | OTHER | 07479760 | 05 | CO | MEDICAID |