Provider Demographics
NPI:1063494086
Name:REDDIVARI, AJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:AJAY
Middle Name:
Last Name:REDDIVARI
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 1:1380 E STROOP RD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-4926
Mailing Address - Country:US
Mailing Address - Phone:937-294-4356
Mailing Address - Fax:937-297-2381
Practice Address - Street 1:1380 E STROOP RD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-4926
Practice Address - Country:US
Practice Address - Phone:937-294-4356
Practice Address - Fax:937-297-2381
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-0503R207RC0000X
OH35060503207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0941600Medicaid
OH0941600Medicaid
OH0741817Medicare PIN
OHF60533Medicare UPIN