1154053395 NPI number — KOTESHWAREDDY VADAGANDLA M.D

Table of content: KOTESHWAREDDY VADAGANDLA M.D (NPI 1154053395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154053395 NPI number — KOTESHWAREDDY VADAGANDLA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VADAGANDLA
Provider First Name:
KOTESHWAREDDY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154053395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2701 DEKALB PIKE, GRADUATE MEDICAL EDUCATION OFFICE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST NORRITON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-278-2003
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 BUTTE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96001-0852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-244-8250
Provider Business Practice Location Address Fax Number:
530-244-5494
Provider Enumeration Date:
06/27/2022

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: 390200000X , with the licence number:  MT225420 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: 12065 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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