Healthcare Provider Details

I. General information

NPI: 1619123890
Provider Name (Legal Business Name): PRASHANTH POTHEM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 JOE FRANK HARRIS PKWY SE
CARTERSVILLE GA
30120-2129
US

IV. Provider business mailing address

1201 W FERTITTA BLVD
LEESVILLE LA
71446-4637
US

V. Phone/Fax

Practice location:
  • Phone: 470-490-2142
  • Fax:
Mailing address:
  • Phone: 248-635-0979
  • Fax: 337-392-6206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number204696
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number95353
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95353
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: