Provider Demographics
NPI:1417915752
Name:POTLURI, JAGADISH (MD)
Entity Type:Individual
Prefix:DR
First Name:JAGADISH
Middle Name:
Last Name:POTLURI
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:PO BOX 13700-1369
Mailing Address - Street 2:COMMONWEALTH EMERGENCY PHYSICIANS PC
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19191-1369
Mailing Address - Country:US
Mailing Address - Phone:800-666-2455
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:44045 RIVERSIDE PARKWAY
Practice Address - Street 2:LOUDOUN HOSPITAL CENTER
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:703-858-6040
Practice Address - Fax:610-617-6280
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101235365207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H68660Medicare UPIN
VA003103C77Medicare ID - Type Unspecified