Provider Demographics
NPI:1194843763
Name:POTHURAJU, VENKATA R (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATA
Middle Name:R
Last Name:POTHURAJU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4930 E LAKE MARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-5003
Mailing Address - Country:US
Mailing Address - Phone:407-322-8645
Mailing Address - Fax:407-330-5074
Practice Address - Street 1:4930 E LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-5003
Practice Address - Country:US
Practice Address - Phone:407-322-8645
Practice Address - Fax:407-330-5074
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000998900Medicaid
FLCH434ZMedicare Oscar/Certification