Provider Demographics
NPI:1902208440
Name:POTTY, ANISH GOVIND RADHAKRISHNAN (MD,)
Entity Type:Individual
Prefix:
First Name:ANISH
Middle Name:GOVIND RADHAKRISHNAN
Last Name:POTTY
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 1:7109 N BARTLETT AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6473
Mailing Address - Country:US
Mailing Address - Phone:956-727-2122
Mailing Address - Fax:956-727-4445
Practice Address - Street 1:7109 N BARTLETT AVE STE 109
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6473
Practice Address - Country:US
Practice Address - Phone:956-727-2122
Practice Address - Fax:956-727-4445
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121143207X00000X
TXQ3076207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX347261501Medicaid
407935YTEOMedicare PIN