Provider Demographics
NPI:1366468944
Name:POTLA, MADHU (MD)
Entity Type:Individual
Prefix:
First Name:MADHU
Middle Name:
Last Name:POTLA
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 1:8787 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE NO 120 B
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-5446
Mailing Address - Country:US
Mailing Address - Phone:864-884-5116
Mailing Address - Fax:
Practice Address - Street 1:8787 N MACARTHUR BLVD
Practice Address - Street 2:SUITE NO 120 B
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-5446
Practice Address - Country:US
Practice Address - Phone:864-884-5116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50946207Q00000X
SD7001207Q00000X
TXP7543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080019283Medicare PIN