Provider Demographics
NPI:1629171681
Name:POTLURI, KESAVA R (MD)
Entity Type:Individual
Prefix:
First Name:KESAVA
Middle Name:R
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 1:7901 RIDGE MILLS RD
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2203
Mailing Address - Country:US
Mailing Address - Phone:315-339-2646
Mailing Address - Fax:315-533-1264
Practice Address - Street 1:7901 RIDGE MILLS RD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2203
Practice Address - Country:US
Practice Address - Phone:315-339-2646
Practice Address - Fax:315-339-2485
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00854426Medicaid
001000600OtherBSUT
115124OtherMVP
B82607Medicare UPIN
115124OtherMVP