Provider Demographics
NPI:1144213422
Name:KETHIREDDY, RAVI REDDY (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:REDDY
Last Name:KETHIREDDY
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 1:5398 PARK ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-1041
Mailing Address - Country:US
Mailing Address - Phone:757-544-1441
Mailing Address - Fax:727-545-8263
Practice Address - Street 1:5398 PARK ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-1041
Practice Address - Country:US
Practice Address - Phone:757-544-1441
Practice Address - Fax:727-545-8263
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57029207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378242500Medicaid
FL27185OtherBCBS OF FLORIDA
FL27185OtherBCBS OF FLORIDA
FLF26880Medicare UPIN
FL27185AMedicare PIN