Healthcare Provider Details

I. General information

NPI: 1053713115
Provider Name (Legal Business Name): KRISHNA KANTH POTLURI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2014
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE # 2A31
NEW YORK NY
10029-7404
US

IV. Provider business mailing address

1901 1ST AVE # 2A31
NEW YORK NY
10029-7404
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number50552
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number289667
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD17431
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD55461
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: