Healthcare Provider Details

I. General information

NPI: 1699752881
Provider Name (Legal Business Name): VISWANADHAM POTHULA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475 BOX 1752
FPO AP
96350
JP

IV. Provider business mailing address

PSC 475 BOX 1752
FPO AP
96350
JP

V. Phone/Fax

Practice location:
  • Phone: 01181468165775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number185852
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: