Provider Demographics
NPI:1437224557
Name:MOKUREDDY, VIDYASAGAR (MD)
Entity Type:Individual
Prefix:
First Name:VIDYASAGAR
Middle Name:
Last Name:MOKUREDDY
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 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:100 JOHN ROEMMELT DR
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8301
Practice Address - Country:US
Practice Address - Phone:607-795-2828
Practice Address - Fax:607-795-2829
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2259762081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019347550001Medicaid
NY02355668Medicaid
NYJ400070007Medicare PIN
NYJ400070007Medicare PIN