Provider Demographics
NPI:1710211487
Name:POTHINI, GOURI BHAWAN (MD)
Entity Type:Individual
Prefix:
First Name:GOURI
Middle Name:BHAWAN
Last Name:POTHINI
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 1:5000 HOPYARD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3146
Mailing Address - Country:US
Mailing Address - Phone:925-924-1600
Mailing Address - Fax:925-924-0506
Practice Address - Street 1:1455 BATTERSBY AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3634
Practice Address - Country:US
Practice Address - Phone:360-802-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD.60729650207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000000Medicaid
NYJ400023298OtherMEDICARE