Provider Demographics
NPI:1730166232
Name:POTLURI, MOHAN D (MD)
Entity type:Individual
Prefix:MR
First Name:MOHAN
Middle Name:D
Last Name:POTLURI
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 1:1662 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4001
Mailing Address - Country:US
Mailing Address - Phone:518-869-9692
Mailing Address - Fax:518-869-7220
Practice Address - Street 1:1662 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4001
Practice Address - Country:US
Practice Address - Phone:518-869-9692
Practice Address - Fax:518-869-7220
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134947208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000400079001OtherURGENT CARE
0061396OtherGHI
4544624OtherAETNA
52E592OtherBLUE CROSS BLUE SHIELD
01138OtherMVP
55582OtherGHI HMO
5500530OtherGHI
000401122000OtherBLUE SHIELD OF NENY
04B091OtherBLUE CROSS BLUE SHIELD
53242OtherGHI HMO
9521451OtherGHI
000461122003OtherBLUE SHIELD OF NENY
01146OtherMVP
10001639OtherCDPHP
01137OtherMVP
000401122001OtherBLUE SHIELD OF NENY
10001639OtherCDPHP
000401122000OtherBLUE SHIELD OF NENY
55582OtherGHI HMO
39754BMedicare ID - Type Unspecified