Basic Information
| Provider Information | |||||||||
| NPI: | 1922085646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTAMPA | ||||||||
| FirstName: | W | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | POTAMPA | ||||||||
| OtherFirstName: | WHITTON | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1101 MADISON ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062152004 | ||||||||
| FaxNumber: | 2062152055 | ||||||||
| Practice Location | |||||||||
| Address1: | 11919 NE 128TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980347204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258216655 | ||||||||
| FaxNumber: | 4258218836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
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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 | 207W00000X | MD00023322 | WA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 180021811 | 01 | RAILROAD MEDICARE | OTHER | 0071123 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8307290 | 05 | WA | MEDICAID | PO3997 | 01 | REGENCE HEALTHCARE | OTHER |