Provider Demographics
NPI:1679640650
Name:REDDY, CHENNA B (MD)
Entity Type:Individual
Prefix:
First Name:CHENNA
Middle Name:B
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 1:9413 FLATLANDS AVENUE
Mailing Address - Street 2:SUITE 101 WEST
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236
Mailing Address - Country:US
Mailing Address - Phone:718-257-6615
Mailing Address - Fax:718-272-3365
Practice Address - Street 1:9413 FLATLANDS AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236
Practice Address - Country:US
Practice Address - Phone:718-257-6615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121755207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00228735Medicaid
B77726Medicare UPIN
NY00228735Medicaid