Provider Demographics
NPI:1437104809
Name:POTURALSKI, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:POTURALSKI
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:730 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4602
Practice Address - Country:US
Practice Address - Phone:419-227-3361
Practice Address - Fax:419-226-9826
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00060423OtherMEDICARE RR
OH000000317858OtherBCBS
OH0559015Medicaid
OHPO4018333Medicare PIN
OH0559015Medicaid
OHP00060423OtherMEDICARE RR