Provider Demographics
NPI:1508962176
Name:REDDY, CHAKRAVARTHY B (MD)
Entity Type:Individual
Prefix:
First Name:CHAKRAVARTHY
Middle Name:B
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SRINIVAS
Other - Middle Name:B
Other - Last Name:CHAKRAVARTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4486 S GILEAD WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-4016
Mailing Address - Country:US
Mailing Address - Phone:801-671-4803
Mailing Address - Fax:
Practice Address - Street 1:26 N 1900 E
Practice Address - Street 2:701, WINTROBE BUILDING
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-581-7806
Practice Address - Fax:801-585-3355
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT52163851205207R00000X
UT5216385-1205207RC0200X, 208M00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1508962176Medicaid
UT1508962176Medicaid
UT005740813Medicare PIN