Provider Demographics
NPI:1346415635
Name:REDDI-DICKASON, RENUKA C (MD)
Entity Type:Individual
Prefix:MRS
First Name:RENUKA
Middle Name:C
Last Name:REDDI-DICKASON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RENUKA
Other - Middle Name:C
Other - Last Name:REDDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3100 N STANTON SUITE A
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902
Mailing Address - Country:US
Mailing Address - Phone:915-594-9600
Mailing Address - Fax:915-594-9601
Practice Address - Street 1:3100 N STANTON SUITE A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902
Practice Address - Country:US
Practice Address - Phone:915-532-9477
Practice Address - Fax:915-545-4813
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0275207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1239782-08Medicaid
TX1239782-07Medicaid
C20920Medicare UPIN
TXTXB127930Medicare PIN