Provider Demographics
NPI:1659383966
Name:POTLA, JAYAPRADA (MD)
Entity Type:Individual
Prefix:
First Name:JAYAPRADA
Middle Name:
Last Name:POTLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JAYAPRADA
Other - Middle Name:
Other - Last Name:NANDIPATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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:864-884-5166
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:864-884-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7542207Q00000X
MN45462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080012505Medicare ID - Type Unspecified
H87183Medicare UPIN
MN450003200Medicaid