Provider Demographics
NPI:1194791392
Name:POTLURI, AJITH KUMAR (MD)
Entity type:Individual
Prefix:
First Name:AJITH
Middle Name:KUMAR
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 1:3391 W VINE ST STE 303
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4665
Mailing Address - Country:US
Mailing Address - Phone:407-962-7449
Mailing Address - Fax:407-932-0303
Practice Address - Street 1:3391 W VINE ST STE 303
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4665
Practice Address - Country:US
Practice Address - Phone:407-962-7449
Practice Address - Fax:407-932-0303
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1150042084P0805X, 2084P0800X, 2084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009920000Medicaid
FLHP309AMedicare PIN