Healthcare Provider Details

I. General information

NPI: 1730166232
Provider Name (Legal Business Name): MOHAN D POTLURI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1662 CENTRAL AVE
ALBANY NY
12205-4001
US

IV. Provider business mailing address

1662 CENTRAL AVE
ALBANY NY
12205-4001
US

V. Phone/Fax

Practice location:
  • Phone: 518-869-9692
  • Fax: 518-869-7220
Mailing address:
  • Phone: 518-869-9692
  • Fax: 518-869-7220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number134947
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number134947
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: