MEDICARE: AJITH KUMAR POTLURI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0805X	Geriatric Psychiatry Physician	ME115004	FL
2	2084P0800X	Psychiatry Physician	ME115004	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194791392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AJITH KUMAR POTLURI M.D.

Provider Business Mailing Address
First Line	:	3391 W VINE ST STE 303
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-4665
Country	:	US
Telephone Number	:	407-962-7449
Fax Number	:	407-932-0303

Provider Business Practice Location Address
First Line	:	3391 W VINE ST STE 303
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-4665
Country	:	US
Telephone Number	:	407-962-7449
Fax Number	:	407-932-0303

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	06/01/2022

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