Provider Demographics
NPI:1639250392
Name:POTHALA, PADMAVATHAMMA (MD)
Entity Type:Individual
Prefix:
First Name:PADMAVATHAMMA
Middle Name:
Last Name:POTHALA
Suffix:
Gender:F
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 200009
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78720-0009
Mailing Address - Country:US
Mailing Address - Phone:512-482-8280
Mailing Address - Fax:512-482-9457
Practice Address - Street 1:1009 E 40TH STREET
Practice Address - Street 2:SUITE 300B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-4812
Practice Address - Country:US
Practice Address - Phone:512-482-8280
Practice Address - Fax:512-482-9457
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0909207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146623702Medicaid
110238080OtherRAILROAD MEDICARE
0082HOOtherBLUE CROSS BLUE SHIELD
0082HOOtherBLUE CROSS BLUE SHIELD
TX00765FMedicare PIN