Basic Information
| Provider Information | |||||||||
| NPI: | 1578770095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTU | ||||||||
| FirstName: | SANGEETHA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601643 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043550720 | ||||||||
| FaxNumber: | 7043555948 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
| Address2: | CMC ANNEX 1ST FLOOR | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043550720 | ||||||||
| FaxNumber: | 7043555948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301084307 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME104915 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | ME104915 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | 2010-01503 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | NC2385 | 05 | SC | MEDICAID | 1578770095 | 05 | NC | MEDICAID |