Provider Demographics
NPI:1235158585
Name:REDDY, GAUTAM M (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:M
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 E SUNRISE HWY
Mailing Address - Street 2:STE. 304
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1329
Mailing Address - Country:US
Mailing Address - Phone:516-825-8484
Mailing Address - Fax:516-825-8491
Practice Address - Street 1:210 E SUNRISE HWY
Practice Address - Street 2:STE. 304
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1329
Practice Address - Country:US
Practice Address - Phone:516-825-8484
Practice Address - Fax:516-825-8491
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200237207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01918863Medicaid
NYWX1001Medicare ID - Type Unspecified
NYG72253Medicare UPIN