Provider Demographics
NPI:1033200993
Name:REDDY, BHAGYAM CHENNA (M D)
Entity Type:Individual
Prefix:DR
First Name:BHAGYAM
Middle Name:CHENNA
Last Name:REDDY
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SULLIVAN WAY
Mailing Address - Street 2:
Mailing Address - City:WEST TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08628-3406
Mailing Address - Country:US
Mailing Address - Phone:609-633-1500
Mailing Address - Fax:
Practice Address - Street 1:301 SULLIVAN WAY
Practice Address - Street 2:
Practice Address - City:WEST TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08628-3406
Practice Address - Country:US
Practice Address - Phone:609-633-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05062500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ716738C2DOtherMEDICARE PROVIDER NUMBER
NJF21891Medicare UPIN