Provider Demographics
NPI:1639389133
Name:REDDY, MADHUSUDHAN P (MD)
Entity Type:Individual
Prefix:
First Name:MADHUSUDHAN
Middle Name:P
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 1:3614 142 PLACE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3231
Mailing Address - Country:US
Mailing Address - Phone:318-675-5000
Mailing Address - Fax:
Practice Address - Street 1:1301 15TH AVE. W.
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3821
Practice Address - Country:US
Practice Address - Phone:701-774-7400
Practice Address - Fax:701-774-7479
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14725R2085R0202X
WA600415272085R0202X
ND117652085R0202X
OH35.0948482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA15376Medicaid