Provider Demographics
NPI:1649384892
Name:REDDY, PRADEEP GOPALA (MD)
Entity Type:Individual
Prefix:MR
First Name:PRADEEP
Middle Name:GOPALA
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 1:3412 OFFICE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1998
Mailing Address - Country:US
Mailing Address - Phone:618-993-0404
Mailing Address - Fax:618-993-1717
Practice Address - Street 1:3412 OFFICE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1998
Practice Address - Country:US
Practice Address - Phone:618-993-0404
Practice Address - Fax:618-993-1717
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361100812080N0001X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
208282Medicare ID - Type Unspecified
I00764Medicare UPIN