Provider Demographics
NPI:1689798449
Name:P. REDDY TUKIVAKALA, M.D., P.A.
Entity Type:Organization
Organization Name:P. REDDY TUKIVAKALA, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRIVETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-338-7441
Mailing Address - Street 1:PO BOX 806
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72342-0806
Mailing Address - Country:US
Mailing Address - Phone:870-338-7441
Mailing Address - Fax:870-338-7945
Practice Address - Street 1:810 NEWMAN DR # A
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-8950
Practice Address - Country:US
Practice Address - Phone:870-338-7441
Practice Address - Fax:870-338-7945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4048261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119045002Medicaid
AR5B386OtherBLUE CROSS
ARD21758Medicare UPIN
AR119045002Medicaid