Healthcare Provider Details

I. General information

NPI: 1083852248
Provider Name (Legal Business Name): VIJAYASIMHA REDDY POTHULA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 LOGAN AVE
WATERLOO IA
50703-1916
US

IV. Provider business mailing address

4150 KIMBALL AVE PO BOX 2758
WATERLOO IA
50701-9086
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-5386
  • Fax: 319-235-3074
Mailing address:
  • Phone: 319-235-5390
  • Fax: 319-233-1630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number40239
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: