Provider Demographics
NPI:1487073615
Name:POTROUS, LAITH MATTI (MD)
Entity type:Individual
Prefix:
First Name:LAITH
Middle Name:MATTI
Last Name:POTROUS
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 1:5843 17 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6873
Mailing Address - Country:US
Mailing Address - Phone:586-722-7741
Mailing Address - Fax:586-883-9970
Practice Address - Street 1:5843 17 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6873
Practice Address - Country:US
Practice Address - Phone:586-722-7741
Practice Address - Fax:586-883-9970
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105756207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty