Provider Demographics
NPI:1467591057
Name:REDDY, GADDAM D (MD)
Entity Type:Individual
Prefix:
First Name:GADDAM
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 1:4343 KISSENA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2950
Mailing Address - Country:US
Mailing Address - Phone:718-886-5680
Mailing Address - Fax:718-353-1814
Practice Address - Street 1:4343 KISSENA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2950
Practice Address - Country:US
Practice Address - Phone:718-886-5680
Practice Address - Fax:718-353-1814
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129299208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00238326Medicaid