Healthcare Provider Details

I. General information

NPI: 1093768400
Provider Name (Legal Business Name): POTHEN C KORUTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

758 N SUN DR ST # 104
LAKE MARY FL
32746-2599
US

IV. Provider business mailing address

758 N SUN DR ST # 104
LAKE MARY FL
32746-2599
US

V. Phone/Fax

Practice location:
  • Phone: 407-333-3303
  • Fax: 407-333-3342
Mailing address:
  • Phone: 407-333-3303
  • Fax: 407-333-3342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0072112
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0072112
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: