Provider Demographics
NPI:1063687556
Name:REDDY, NALLU S (MD)
Entity Type:Individual
Prefix:
First Name:NALLU
Middle Name:S
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:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33092-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-2052
Mailing Address - Fax:239-343-5348
Practice Address - Street 1:2776 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5855
Practice Address - Country:US
Practice Address - Phone:239-343-2052
Practice Address - Fax:239-343-5348
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100925207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1451XOtherBC/BS
FL104692000Medicaid
BH070YOtherMEDICARE PTAN