Provider Demographics
NPI:1215255633
Name:POTEPALOV, SERGEY SERGEYEVICH (MD)
Entity type:Individual
Prefix:DR
First Name:SERGEY
Middle Name:SERGEYEVICH
Last Name:POTEPALOV
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:500 W MEDICAL CENTER BLVD
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4220
Mailing Address - Country:US
Mailing Address - Phone:281-338-3708
Mailing Address - Fax:281-338-3224
Practice Address - Street 1:500 W MEDICAL CENTER BLVD
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4220
Practice Address - Country:US
Practice Address - Phone:281-338-3708
Practice Address - Fax:281-338-3224
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2015-10-29
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAMD.20529207P00000X
TXP9695207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX337030602Medicaid
LA2103610Medicaid