Provider Demographics
NPI:1710996384
Name:REDDY, REDDIWANDLA SEENU (MD)
Entity Type:Individual
Prefix:
First Name:REDDIWANDLA
Middle Name:SEENU
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 1:5565 GROSSMONT CENTER DR. BLDG.1 SUITE 202
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-461-6130
Mailing Address - Fax:619-461-3108
Practice Address - Street 1:5565 GROSSMONT CENTER DR. BLDG.1 SUITE 202
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-461-6130
Practice Address - Fax:619-461-3108
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38098207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A380980Medicaid
CAA88443Medicare UPIN
CA00A380980Medicaid