=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093768400
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | POTHEN C KORUTH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 03/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 758 N SUN DR ST # 104
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-2599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-333-3303
-----------------------------------------------------
Fax | 407-333-3342
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 758 N SUN DR ST # 104
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-2599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-333-3303
-----------------------------------------------------
Fax | 407-333-3342
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME0072112
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME0072112
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------