Provider Demographics
NPI:1093768400
Name:KORUTH, POTHEN C (MD)
Entity Type:Individual
Prefix:
First Name:POTHEN
Middle Name:C
Last Name:KORUTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 N SUN DR
Mailing Address - Street 2:ST # 104
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2599
Mailing Address - Country:US
Mailing Address - Phone:407-333-3303
Mailing Address - Fax:407-333-3342
Practice Address - Street 1:758 N SUN DR
Practice Address - Street 2:ST # 104
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2599
Practice Address - Country:US
Practice Address - Phone:407-333-3303
Practice Address - Fax:407-333-3342
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072112174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269423900Medicaid
FL42250BMedicare ID - Type Unspecified