Provider Demographics
NPI:1134127681
Name:REDDY, SHANTHI G (MD PA)
Entity Type:Individual
Prefix:DR
First Name:SHANTHI
Middle Name:G
Last Name:REDDY
Suffix:
Gender:F
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30062
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657-1062
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
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2010-08-18
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
TXJ3587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ3587OtherSTATE LICENSE
TX136418406Medicaid
TX136418408Medicaid
F65496OtherUPIN #
TX0002CFOtherBLUE CROSS ID
TX136418401Medicaid
TX45D0937526OtherCLIA