Provider Demographics
NPI:1689872848
Name:REDDY, SHANTAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANTAN
Middle Name:G
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 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:1415 SANTA FE ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2105
Practice Address - Country:US
Practice Address - Phone:361-885-0390
Practice Address - Fax:361-904-0178
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD200535207RX0202X, 207RH0002X
TXP9943207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1070700Medicaid
TX280554102Medicaid
LA1070700Medicaid
TX280554102Medicaid
TX385702YMJMMedicare PIN