Provider Demographics
NPI:1558341602
Name:BODHIREDDY, SURENDER R (MD)
Entity Type:Individual
Prefix:DR
First Name:SURENDER
Middle Name:R
Last Name:BODHIREDDY
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 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:806-725-4271
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:3615 19TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1203
Practice Address - Country:US
Practice Address - Phone:806-744-1887
Practice Address - Fax:806-744-5545
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2185207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220027645OtherMC RR
TXP084P0312Medicaid
TX84P031OtherBCBS
TX220027645OtherMC RR
TXP084P0312Medicaid