Provider Demographics
NPI:1609929397
Name:REDDY, DEEPA K (MD)
Entity Type:Individual
Prefix:
First Name:DEEPA
Middle Name:K
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 1:2755 ALAMO ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1311
Mailing Address - Country:US
Mailing Address - Phone:805-210-7280
Mailing Address - Fax:
Practice Address - Street 1:2755 ALAMO ST STE 101
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1311
Practice Address - Country:US
Practice Address - Phone:805-210-7280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8447799Medicaid
WAG8859163Medicare PIN
WAG8859166Medicare PIN
WA8447799Medicaid
WAG8859165Medicare PIN
WAG8859164Medicare PIN
WAI50517Medicare UPIN
WAG8872509Medicare PIN