Provider Demographics
NPI:1841426947
Name:POTTALA, SREELATHA (MD)
Entity Type:Individual
Prefix:
First Name:SREELATHA
Middle Name:
Last Name:POTTALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SREELATHA
Other - Middle Name:
Other - Last Name:POTTALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MBBS
Mailing Address - Street 1:P.O. BOX 1020
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-1020
Mailing Address - Country:US
Mailing Address - Phone:209-468-6000
Mailing Address - Fax:209-468-7042
Practice Address - Street 1:500 W. HOSPITAL RD.
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9989
Practice Address - Country:US
Practice Address - Phone:209-468-6820
Practice Address - Fax:209-468-6132
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117291207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841426947Medicaid