Provider Demographics
NPI:1205848595
Name:REDDY, TIYYAGURA S
Entity Type:Individual
Prefix:
First Name:TIYYAGURA
Middle Name:S
Last Name:REDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2236
Mailing Address - Country:US
Mailing Address - Phone:727-499-0358
Mailing Address - Fax:727-781-3312
Practice Address - Street 1:7614 JACQUE RD STE B
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7195
Practice Address - Country:US
Practice Address - Phone:727-863-2105
Practice Address - Fax:727-862-2512
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40196207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
110012967OtherRAILROAD MEDICARE
FL211156OtherAVMED
FL167251OtherWELLCARE
FL51256OtherBLUE CROS BLUE SHIELD
FL042172300Medicaid
FL211156OtherAVMED
FL042172300Medicaid