Provider Demographics
NPI:1558371807
Name:REDDY, CHALLORI J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHALLORI
Middle Name:J
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:PO BOX 14804
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915
Mailing Address - Country:US
Mailing Address - Phone:912-384-1477
Mailing Address - Fax:912-384-1470
Practice Address - Street 1:2007 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2229
Practice Address - Country:US
Practice Address - Phone:912-384-0162
Practice Address - Fax:912-384-4863
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029936174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA029936OtherSTATE LICENSE NUMBER
GA00346717AMedicaid
GA00346717AMedicaid