Provider Demographics
NPI:1548269012
Name:POTHOULAKIS, ANTHONY JOHN (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOHN
Last Name:POTHOULAKIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10600 MEDLOCK BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 PHILIP BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8736
Practice Address - Country:US
Practice Address - Phone:770-995-3300
Practice Address - Fax:770-995-3307
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2023-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA072758207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003151345Medicaid
GA003151345Medicaid
GA202I062622Medicare PIN