Provider Demographics
NPI:1043224496
Name:REDDY, GADDUM JM
Entity Type:Individual
Prefix:
First Name:GADDUM
Middle Name:JM
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 1:3105 MOUNTAIN SHADOW
Mailing Address - Street 2:
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-6645
Mailing Address - Country:US
Mailing Address - Phone:432-263-7361
Mailing Address - Fax:
Practice Address - Street 1:300 W VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-5566
Practice Address - Country:US
Practice Address - Phone:432-263-7361
Practice Address - Fax:432-264-4882
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00008168208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXVAD000Medicare UPIN