Provider Demographics
NPI:1548233190
Name:REDDY, PESARA P (MD)
Entity Type:Individual
Prefix:
First Name:PESARA
Middle Name:P
Last Name:REDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W 12TH ST
Mailing Address - Street 2:THE REGIONAL CANCER CTR
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505
Mailing Address - Country:US
Mailing Address - Phone:814-835-9000
Mailing Address - Fax:814-838-0443
Practice Address - Street 1:2500 W 12TH ST
Practice Address - Street 2:THE REGIONAL CANCER CTR
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505
Practice Address - Country:US
Practice Address - Phone:814-835-9000
Practice Address - Fax:814-838-0443
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034289L2085R0203X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006903140001Medicaid
OH2193611Medicaid
PA0006903140001Medicaid