1063458735 NPI number — DR. SUDHAKAR A REDDY MD

Table of content: DR. SUDHAKAR A REDDY MD (NPI 1063458735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063458735 NPI number — DR. SUDHAKAR A REDDY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDDY
Provider First Name:
SUDHAKAR
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REDDY
Provider Other First Name:
SUDY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1063458735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5555 E BASELINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85206-4709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-393-5075
Provider Business Mailing Address Fax Number:
480-704-4019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5555 E BASELINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-4709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-393-5075
Provider Business Practice Location Address Fax Number:
480-704-4019
Provider Enumeration Date:
06/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  MD043886E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 36640 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 194943 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01748642 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".