Provider Demographics
NPI:1215969548
Name:POTHIAWALA, YAKUB AHMED (MD)
Entity type:Individual
Prefix:MR
First Name:YAKUB
Middle Name:AHMED
Last Name:POTHIAWALA
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 1:3865 NORTHDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624
Mailing Address - Country:US
Mailing Address - Phone:813-960-4401
Mailing Address - Fax:813-265-1258
Practice Address - Street 1:3865 NORTHDALE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624
Practice Address - Country:US
Practice Address - Phone:813-960-4401
Practice Address - Fax:813-265-1258
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0070225207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251408700Medicaid
FL251408700Medicaid
G23323Medicare UPIN
FL31721AMedicare PIN