Provider Demographics
NPI:1114451630
Name:REDDY, MAHIDHAR MAHASAMUDRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHIDHAR
Middle Name:MAHASAMUDRAM
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 1:12 CEDAR GATE DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039
Mailing Address - Country:US
Mailing Address - Phone:848-992-4223
Mailing Address - Fax:
Practice Address - Street 1:1199 PLEASANT VALLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1424
Practice Address - Country:US
Practice Address - Phone:973-830-7694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11750000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine