Provider Demographics
NPI:1104015775
Name:REDDY, SUDESH S (MD INC)
Entity Type:Individual
Prefix:
First Name:SUDESH
Middle Name:S
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S STATE ST
Mailing Address - Street 2:MARION
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-5000
Mailing Address - Country:US
Mailing Address - Phone:740-387-0650
Mailing Address - Fax:
Practice Address - Street 1:402 S STATE ST
Practice Address - Street 2:MARION
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-5000
Practice Address - Country:US
Practice Address - Phone:740-387-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-053263207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0673114Medicaid
D42313Medicare UPIN
OH0673114Medicaid