Provider Demographics
NPI:1992714117
Name:POTDAR, SHAILAJA (MD)
Entity type:Individual
Prefix:
First Name:SHAILAJA
Middle Name:
Last Name:POTDAR
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 1:311 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2911
Mailing Address - Country:US
Mailing Address - Phone:315-425-1431
Mailing Address - Fax:
Practice Address - Street 1:311 GREEN ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2911
Practice Address - Country:US
Practice Address - Phone:315-425-1431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196775208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01769942Medicaid
370008549OtherRR
370008549OtherRR
SP086J5510Medicare ID - Type Unspecified
G17134Medicare UPIN