Provider Demographics
NPI:1043299746
Name:REDDY, BOUYELLA H (MD)
Entity Type:Individual
Prefix:DR
First Name:BOUYELLA
Middle Name:H
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 E RUSHOLME ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2434
Mailing Address - Country:US
Mailing Address - Phone:563-324-2992
Mailing Address - Fax:563-324-8562
Practice Address - Street 1:1100 36TH AVENUE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-743-6700
Practice Address - Fax:309-743-6709
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097680207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA7168971Medicaid
IL036097680Medicaid
P00180524OtherMEDICARE RAILROAD
F32707Medicare UPIN
ILK12788Medicare PIN
IA7168971Medicaid