Provider Demographics
NPI:1316071830
Name:POTHIWALA, POOJA S (MD)
Entity type:Individual
Prefix:
First Name:POOJA
Middle Name:S
Last Name:POTHIWALA
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:421 COMMERCIAL CT STE A
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-1656
Practice Address - Country:US
Practice Address - Phone:941-499-0800
Practice Address - Fax:941-499-0801
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110866207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004429000Medicaid
FLP01026112OtherMEDICARE RAILROAD
FLFT519ZMedicare PIN