Provider Demographics
NPI:1083852248
Name:POTHULA, VIJAYASIMHA REDDY (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYASIMHA
Middle Name:REDDY
Last Name:POTHULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4150 KIMBALL AVE
Mailing Address - Street 2:PO BOX 2758
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-9086
Mailing Address - Country:US
Mailing Address - Phone:319-235-5390
Mailing Address - Fax:319-233-1630
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-5386
Practice Address - Fax:319-235-3074
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2012-06-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA40239207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology