Provider Demographics
NPI:1609844984
Name:JEEREDDI, SUDATHI (MD)
Entity Type:Individual
Prefix:
First Name:SUDATHI
Middle Name:
Last Name:JEEREDDI
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 1:840 TOWNE CENTER DR
Mailing Address - Street 2:CHAPARRAL MEDICAL GROUP
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:790 EAST BONITA AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1906
Practice Address - Country:US
Practice Address - Phone:909-447-8585
Practice Address - Fax:909-447-8593
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A322640Medicaid
CAWA32264GMedicare PIN
CA080041661Medicare PIN
CA00A322640Medicaid
CAWA32264AMedicare PIN
CA080159558Medicare PIN
CA00A322641Medicare PIN