Provider Demographics
NPI:1114244845
Name:SHANTHI G REDDY MD PA
Entity Type:Organization
Organization Name:SHANTHI G REDDY MD PA
Other - Org Name:DR SHANTHI G REDDY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANTHI
Authorized Official - Middle Name:G
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:409-755-3600
Mailing Address - Street 1:1233 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657-7390
Mailing Address - Country:US
Mailing Address - Phone:409-755-3600
Mailing Address - Fax:409-755-4443
Practice Address - Street 1:1233 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:TX
Practice Address - Zip Code:77657-7390
Practice Address - Country:US
Practice Address - Phone:409-755-3600
Practice Address - Fax:409-755-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F24399OtherMEDICARE INDIVIDUAL PTAN
TX1134127681OtherNPI -INDIVIDUAL
TXJ3587OtherTEXAS LICENSE
TX0A6210OtherMEDICARE GROUP PTAN
TX1114244845OtherGROUP NPI
TX1114244845OtherGROUP NPI
TX1134127681OtherNPI -INDIVIDUAL