Provider Demographics
NPI:1487835260
Name:REDDY, PULI PRAVIN (MD)
Entity Type:Individual
Prefix:MR
First Name:PULI
Middle Name:PRAVIN
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 1:1418 DRESDEN DRIVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319
Mailing Address - Country:US
Mailing Address - Phone:404-481-5089
Mailing Address - Fax:404-795-0461
Practice Address - Street 1:1418 DRESDEN DRIVE
Practice Address - Street 2:120
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319
Practice Address - Country:US
Practice Address - Phone:404-481-5089
Practice Address - Fax:404-795-0461
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240739208200000X
GA0462202086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GATAX IDOther26-3609921