Provider Demographics
NPI:1003349820
Name:REDDY, KANUBODDU NAGARJUNA
Entity Type:Individual
Prefix:
First Name:KANUBODDU
Middle Name:NAGARJUNA
Last Name:REDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4896
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:700 NE 87TH AVE STE 220
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-4896
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-08
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143491207R00000X
WAMD61164297207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine