Provider Demographics
NPI:1679151732
Name:POTHEN, SOPHIA (DO)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:POTHEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 LEE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-5561
Mailing Address - Country:US
Mailing Address - Phone:407-723-7373
Mailing Address - Fax:407-723-4842
Practice Address - Street 1:904 LEE RD STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-5561
Practice Address - Country:US
Practice Address - Phone:407-723-7373
Practice Address - Fax:407-723-4842
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS20981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA353616220012Medicaid