Provider Demographics
NPI:1063458735
Name:REDDY, SUDHAKAR A (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHAKAR
Middle Name:A
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SUDY
Other - Middle Name:A
Other - Last Name:REDDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5555 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4709
Mailing Address - Country:US
Mailing Address - Phone:480-393-5075
Mailing Address - Fax:480-704-4019
Practice Address - Street 1:5555 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4709
Practice Address - Country:US
Practice Address - Phone:480-393-5075
Practice Address - Fax:480-704-4019
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043886E207RG0100X
AZ36640207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ194943Medicaid
PA01748642Medicaid
AZZ132643Medicare PIN
PA01748642Medicaid