Provider Demographics
NPI:1376036186
Name:POTTER, DAVID JAESON (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JAESON
Last Name:POTTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10464 S JORDAN GTWY UNIT 477
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5409
Mailing Address - Country:US
Mailing Address - Phone:435-650-5579
Mailing Address - Fax:
Practice Address - Street 1:20 W 7200 S
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-3723
Practice Address - Country:US
Practice Address - Phone:801-561-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9068966-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist