Provider Demographics
NPI:1710118278
Name:REDDY, PRATHIMA KAPADI BASAVA (M D)
Entity Type:Individual
Prefix:
First Name:PRATHIMA
Middle Name:KAPADI BASAVA
Last Name:REDDY
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 W NELSON ST
Mailing Address - Street 2:APT. 701
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5152
Mailing Address - Country:US
Mailing Address - Phone:501-352-9983
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:ADVOCATE ILLINOIS MASONIC MEDICAL CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:501-352-9983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60610289207R00000X
ARE-7615207R00000X, 208M00000X
IL125056499390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE-7615OtherARKANSAS STATE MEDICAL BOARD LICENSE