Provider Demographics
NPI:1417964917
Name:REDDY, DWARAKNATH PONNALUR (MD)
Entity Type:Individual
Prefix:
First Name:DWARAKNATH
Middle Name:PONNALUR
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 1:811 E 11TH ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4871
Mailing Address - Country:US
Mailing Address - Phone:909-629-5540
Mailing Address - Fax:909-946-3070
Practice Address - Street 1:811 E 11TH ST
Practice Address - Street 2:SUITE 208
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4871
Practice Address - Country:US
Practice Address - Phone:909-629-5540
Practice Address - Fax:909-946-3070
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34093207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A340931Medicaid
CA00A340930Medicare ID - Type Unspecified
CA00A340931Medicaid