Provider Demographics
NPI:1073597217
Name:REDDY, SUDARSHAN R (MD)
Entity Type:Individual
Prefix:
First Name:SUDARSHAN
Middle Name:R
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 1:43281 COMMONS
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-263-6050
Mailing Address - Fax:586-263-0436
Practice Address - Street 1:43281 COMMONS
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-263-6050
Practice Address - Fax:586-263-0436
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039506208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1572763024Medicaid
MIA73212OtherHAP
MI15726310Medicaid
MI2405003712OtherBCBS
MIOP62940Medicare PIN
MIA73212OtherHAP
MI1572763024Medicaid
MI0500371Medicare ID - Type Unspecified