Provider Demographics
NPI:1528043163
Name:REDDY, PRAKASH V (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASH
Middle Name:V
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 6TH AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3204
Practice Address - Country:US
Practice Address - Phone:321-312-3501
Practice Address - Fax:321-723-9176
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83944207RS0012X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272481200Medicaid
FL64150XOtherMEDICARE
FL272481200Medicaid
H51268Medicare UPIN
FL64150ZMedicare PIN