Provider Demographics
NPI:1407807100
Name:ETTYREDDY, MOHAN (MD)
Entity Type:Individual
Prefix:MR
First Name:MOHAN
Middle Name:
Last Name:ETTYREDDY
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:465 W PUTNAM
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257
Practice Address - Country:US
Practice Address - Phone:559-784-1110
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82879207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A828790OtherBS OF CA
CA00A828790Medicaid
CA00A828790OtherBS OF CA
CA00A828790Medicaid