Provider Demographics
NPI:1003816331
Name:REDDY, PODDUTURU SRIDHAR (MD, MPH)
Entity Type:Individual
Prefix:MR
First Name:PODDUTURU
Middle Name:SRIDHAR
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:MR
Other - First Name:SRIDHAR
Other - Middle Name:PODDUTURU
Other - Last Name:REDDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:2615 ELECTRIC AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-990-8222
Mailing Address - Fax:810-937-5592
Practice Address - Street 1:2615 ELECTRIC AVENUE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-990-8222
Practice Address - Fax:810-937-5592
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055094207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4153017Medicaid
M92910002Medicare ID - Type Unspecified
MI4153017Medicaid