Provider Demographics
NPI:1679641104
Name:REDDY, ARCHANA P (MD)
Entity Type:Individual
Prefix:
First Name:ARCHANA
Middle Name:P
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 1:6196 TRACEL DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-4761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:209-468-6820
Practice Address - Fax:209-468-6103
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54793207RE0101X
MI4301085553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
700H262220OtherBLUE CROSS-BLUE CROSS
AR085553OtherCHAMPUS-CHAMPUS
MI478704510Medicaid
AR085553OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262220OtherBLUE CROSS-BLUE CROSS
0H26222751Medicare ID - Type Unspecified