Provider Demographics
NPI:1013105170
Name:POTLURI, SREE VISHNU
Entity Type:Individual
Prefix:
First Name:SREE VISHNU
Middle Name:
Last Name:POTLURI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 BROADWAY
Mailing Address - Street 2:2H
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-6353
Mailing Address - Country:US
Mailing Address - Phone:317-371-5568
Mailing Address - Fax:
Practice Address - Street 1:85 BROADWAY
Practice Address - Street 2:2B
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-6353
Practice Address - Country:US
Practice Address - Phone:317-371-5568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008901A225100000X
MI5501012700225100000X
NJ40QA01317300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist