Provider Demographics
NPI:1780989103
Name:LIAMOT VASCULAR IMAGING
Entity type:Organization
Organization Name:LIAMOT VASCULAR IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRATHIBHA
Authorized Official - Middle Name:
Authorized Official - Last Name:POTHARLANKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-298-2910
Mailing Address - Street 1:30 BELMONT CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NJ
Mailing Address - Zip Code:08022-9714
Mailing Address - Country:US
Mailing Address - Phone:609-298-2910
Mailing Address - Fax:609-450-7224
Practice Address - Street 1:30 BELMONT CIR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NJ
Practice Address - Zip Code:08022-9714
Practice Address - Country:US
Practice Address - Phone:609-298-2910
Practice Address - Fax:609-450-7224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-15
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208800000X, 207RC0000X, 2084N0400X, 2085R0202X, 207RP1001X
NJ25MA08401100207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ209093Medicare PIN