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General NPI Number Information
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NPI Number | 1013701036
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Entity Type | Individual
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Provider Name | ISSAC POTHEN BRIAN MD
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Gender | Male
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Dates
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Enumeration Date | 04/07/2025
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Last Update Date | 04/07/2025
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Provider Practice Location Address
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Address Line | 2501 N PATTERSON ST
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City | VALDOSTA
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State | GA
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Zip | 31602-1735
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Country | US
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Telephone | 678-906-0068
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Fax |
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Provider Business Mailing Address
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Address Line | 313 WESTMINISTER LN SW
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City | LILBURN
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State | GA
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Zip | 30047-3063
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Country | US
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Telephone | 678-906-0068
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 17085
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License Number State | GA
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