Provider Demographics
NPI:1659387124
Name:POTTI, KRISHNAN (MD PC)
Entity Type:Individual
Prefix:DR
First Name:KRISHNAN
Middle Name:
Last Name:POTTI
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 BROADWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-769-4616
Mailing Address - Fax:219-736-0719
Practice Address - Street 1:8300 BROADWAY
Practice Address - Street 2:SUITE B
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8602
Practice Address - Country:US
Practice Address - Phone:219-769-4616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025043A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100158100Medicaid
IN457150AMedicare PIN
INE86130Medicare UPIN