Provider Demographics
NPI:1710989546
Name:PEDDIREDDY, RAVIKUMAR R (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVIKUMAR
Middle Name:R
Last Name:PEDDIREDDY
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:G1071 N BALLENGER HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-4453
Mailing Address - Country:US
Mailing Address - Phone:810-234-1651
Mailing Address - Fax:810-257-0694
Practice Address - Street 1:G1071 N BALLENGER HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4453
Practice Address - Country:US
Practice Address - Phone:810-234-1651
Practice Address - Fax:810-257-0694
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058453207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3054785Medicaid
MI3054785Medicaid
0252719Medicare ID - Type Unspecified
F77738Medicare UPIN