Provider Demographics
NPI:1710131305
Name:POTHULOORI, ANTARA PRATAP (MD)
Entity Type:Individual
Prefix:
First Name:ANTARA
Middle Name:PRATAP
Last Name:POTHULOORI
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 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:8901 W DODGE RD
Practice Address - Street 2:STE. 200B
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3327
Practice Address - Country:US
Practice Address - Phone:402-354-1700
Practice Address - Fax:402-354-2055
Is Sole Proprietor?:No
Enumeration Date:2008-11-09
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104060207V00000X
CO50575207V00000X
KY47814207V00000X
NE25791207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731799Medicaid
NE10026301600Medicaid
IA1710131305Medicaid
NE10026480100Medicaid
NE10026480100Medicaid