Provider Demographics
NPI:1407906902
Name:REDDY, MAKALA (MD)
Entity Type:Individual
Prefix:
First Name:MAKALA
Middle Name:
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 1:18523 CORWIN RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2338
Mailing Address - Country:US
Mailing Address - Phone:760-242-5116
Mailing Address - Fax:760-242-5217
Practice Address - Street 1:18523 CORWIN RD
Practice Address - Street 2:SUITE F
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2338
Practice Address - Country:US
Practice Address - Phone:760-242-5116
Practice Address - Fax:760-242-5217
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA326150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA26864Medicare UPIN
CAA326150Medicare ID - Type UnspecifiedLICENSES NUMBER