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NPI Code Detail

MEDICARE: DR. KALYAN CHAKRAVARTHY POTU M.D.

MEDICARE: DR. KALYAN CHAKRAVARTHY POTU 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
1207R00000XInternal Medicine Physician0135SD
2207RC0000XCardiovascular Disease Physician036148458IL

General Provider Information

NPI Number : 1861834897
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KALYAN CHAKRAVARTHY POTU M.D.
Provider Business Mailing Address
First Line : 530 N.E. GLEN OAK AVENUE
Second Line :
City : PEORIA
State : IL
Zip : 61637
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 530 NE GLEN OAK AVE
Second Line :
City : PEORIA
State : IL
Zip : 61637-1554
Country : US
Telephone Number : 309-624-3598
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/18/2013
Last Update Date : 10/07/2024

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