Healthcare Provider Details

I. General information

NPI: 1790740041
Provider Name (Legal Business Name): SANTOSH POTDAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17222 HOSPITAL BLVD STE 116
BROOKSVILLE FL
34601-8925
US

IV. Provider business mailing address

17222 HOSPITAL BLVD STE 116
BROOKSVILLE FL
34601-8925
US

V. Phone/Fax

Practice location:
  • Phone: 352-877-4749
  • Fax: 352-283-8697
Mailing address:
  • Phone: 352-877-4749
  • Fax: 352-283-8697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35089317
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME114536
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number35089317
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: