Provider Demographics
NPI:1295761690
Name:POTHARLANKA, PRATHIBHA (MD)
Entity type:Individual
Prefix:
First Name:PRATHIBHA
Middle Name:
Last Name:POTHARLANKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BELMONT CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NJ
Mailing Address - Zip Code:08022-9714
Mailing Address - Country:US
Mailing Address - Phone:609-789-0800
Mailing Address - Fax:609-298-0491
Practice Address - Street 1:218 SUNSET RD
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1110
Practice Address - Country:US
Practice Address - Phone:609-835-2900
Practice Address - Fax:856-566-2797
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07690100207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0078875Medicaid
NJ0033120Medicaid
NJ7221574OtherAETNA PPO
NJP00603546-MERCEROtherRAILROAD MEDICARE
NJ083658Medicare ID - Type Unspecified
NJ083658ZPCNMedicare PIN
NJI17099Medicare UPIN
NJ083658XPFMedicare PIN