Provider Demographics
NPI:1376530253
Name:REDDY, MALLIKARJUNA D (MD)
Entity Type:Individual
Prefix:DR
First Name:MALLIKARJUNA
Middle Name:D
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 1:7218 164TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4222
Mailing Address - Country:US
Mailing Address - Phone:718-969-6640
Mailing Address - Fax:718-969-1050
Practice Address - Street 1:7218 164TH ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11365-4222
Practice Address - Country:US
Practice Address - Phone:718-969-6640
Practice Address - Fax:718-969-1050
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182618207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01281516Medicaid
00020GMedicare ID - Type Unspecified
E73719Medicare UPIN