Healthcare Provider Details

I. General information

NPI: 1457386583
Provider Name (Legal Business Name): MADHU M POTLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3499
US

IV. Provider business mailing address

500 NE MULTNOMAH ST STE 100
PORTLAND OR
97232-2031
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax:
Mailing address:
  • Phone: 800-813-2000
  • Fax: 503-215-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60647780
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD23160
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: