Provider Demographics
NPI:1902819592
Name:POTARAJU, K PRASAD (MD)
Entity Type:Individual
Prefix:DR
First Name:K PRASAD
Middle Name:
Last Name:POTARAJU
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 1:5858 MYRICK RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-7934
Mailing Address - Country:US
Mailing Address - Phone:614-389-3353
Mailing Address - Fax:614-389-3353
Practice Address - Street 1:5858 MYRICK RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-7934
Practice Address - Country:US
Practice Address - Phone:614-389-3353
Practice Address - Fax:614-389-3353
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH744902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2166374Medicaid
OH0873314Medicare PIN
OH2166374Medicaid