Provider Demographics
NPI:1548203961
Name:REDDY, VINAY MOOLA (MD)
Entity Type:Individual
Prefix:
First Name:VINAY
Middle Name:MOOLA
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 1:8825 BELLA TERRA PL
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-8850
Mailing Address - Country:US
Mailing Address - Phone:916-419-5939
Mailing Address - Fax:
Practice Address - Street 1:4420 DUCKHORN DR #200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834
Practice Address - Country:US
Practice Address - Phone:916-419-9900
Practice Address - Fax:916-419-9699
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63460208VP0000X, 208VP0014X
CA00A63460208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20-0221101OtherCIGNA
CA20-0221101OtherAETNA
20-0221101OtherBLUE SHIELD
CA20-0221101OtherBLUE CROSS
CA20-0221101OtherUNITED
CA200221101OtherTAX ID#
CAP00148938OtherRAILROAD MEDICARE
CA20-0221101OtherBLUE CROSS
CAG90110Medicare UPIN