Provider Demographics
NPI:1053510305
Name:DR MANOHAR G REDDY MD PA
Entity Type:Organization
Organization Name:DR MANOHAR G REDDY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANOHAR
Authorized Official - Middle Name:G
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-752-5544
Mailing Address - Street 1:2551 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8954
Mailing Address - Country:US
Mailing Address - Phone:321-752-5544
Mailing Address - Fax:321-752-5957
Practice Address - Street 1:2551 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8954
Practice Address - Country:US
Practice Address - Phone:321-752-5544
Practice Address - Fax:321-752-5957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073885207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG63683Medicare UPIN