Provider Demographics
NPI:1629086244
Name:KANMANTHA REDDY, JAYAKAR REDDY (MD)
Entity Type:Individual
Prefix:
First Name:JAYAKAR REDDY
Middle Name:
Last Name:KANMANTHA 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 7752
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-7752
Mailing Address - Country:US
Mailing Address - Phone:248-666-2756
Mailing Address - Fax:248-666-2646
Practice Address - Street 1:1255 NORTH OAKLAND BOULEVARD
Practice Address - Street 2:SUITE 175
Practice Address - City:WATERFORD TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48327
Practice Address - Country:US
Practice Address - Phone:248-666-2756
Practice Address - Fax:248-666-2646
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068131207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP02540Medicare ID - Type Unspecified
82269Medicare UPIN