Provider Demographics
NPI:1114955457
Name:REDDY, JITHENDER (MD)
Entity Type:Individual
Prefix:
First Name:JITHENDER
Middle Name:
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 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:770-838-8563
Practice Address - Street 1:523 DIXIE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3870
Practice Address - Country:US
Practice Address - Phone:770-456-3722
Practice Address - Fax:770-456-3785
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC267152084P0800X
GA0644502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC267151Medicaid
SCI09913Medicare UPIN
SCAA05093361Medicare PIN