Provider Demographics
NPI:1689863227
Name:JEFFRY POTASH MD PC
Entity type:Organization
Organization Name:JEFFRY POTASH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:POTASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-254-4947
Mailing Address - Street 1:63 BELMONT AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301
Mailing Address - Country:US
Mailing Address - Phone:802-254-4947
Mailing Address - Fax:802-257-1454
Practice Address - Street 1:63 BELMONT AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301
Practice Address - Country:US
Practice Address - Phone:802-254-4947
Practice Address - Fax:802-257-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420009254207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VN1354Medicare PIN