Provider Demographics
NPI:1073514543
Name:REDDY, KOLLI PRABHAKARA (MD)
Entity Type:Individual
Prefix:DR
First Name:KOLLI
Middle Name:PRABHAKARA
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 1:520 SW 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:FL
Mailing Address - Zip Code:32696
Mailing Address - Country:US
Mailing Address - Phone:352-528-3770
Mailing Address - Fax:352-528-0691
Practice Address - Street 1:520 SW 5TH AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696
Practice Address - Country:US
Practice Address - Phone:352-528-3770
Practice Address - Fax:352-528-0691
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME21372207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
38011Medicare ID - Type Unspecified
D85691Medicare UPIN