Provider Demographics
NPI:1679562953
Name:POTLURI, RAJENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJENDRA
Middle Name:
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2731
Practice Address - Fax:701-234-2158
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9227208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND22610OtherBLUE SHIELD
ND12271Medicaid
ND28580OtherBLUE SHIELD
NDCF8850OtherRAILROAD MEDICARE
ND28582OtherBLUE SHIELD
ND28579OtherBLUE SHIELD
ND28581OtherBLUE SHIELD
ND25978OtherBLUE SHIELD
ND28583OtherBLUE SHIELD
NDP00003010OtherRAILROAD MEDICARE
NDN22610Medicare PIN
NDCF8850Medicare PIN
NDP00003010Medicare PIN
ND28582OtherBLUE SHIELD