Provider Demographics
NPI:1144206301
Name:POTTI, DEEPA RETNEM (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:RETNEM
Last Name:POTTI
Suffix:
Gender:F
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12208 N NC HIGHWAY 150
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9730
Practice Address - Country:US
Practice Address - Phone:336-764-2324
Practice Address - Fax:336-764-9541
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64087182Medicaid
KY0905220Medicare ID - Type Unspecified
KY64087182Medicaid
KY0692928Medicare ID - Type Unspecified
KY0693028Medicare ID - Type Unspecified