Provider Demographics
NPI:1164454161
Name:REDDY, GOPAL (MD)
Entity Type:Individual
Prefix:
First Name:GOPAL
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 1:455 S LIVERNOIS
Mailing Address - Street 2:STE B23
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2578
Mailing Address - Country:US
Mailing Address - Phone:248-651-8888
Mailing Address - Fax:248-651-2400
Practice Address - Street 1:455 S LIVERNOIS
Practice Address - Street 2:STE B23
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-2578
Practice Address - Country:US
Practice Address - Phone:248-651-8888
Practice Address - Fax:248-651-2400
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040965207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3022173Medicaid
A77580Medicare UPIN
MION23900002Medicare ID - Type Unspecified