Provider Demographics
NPI:1790170223
Name:REDDY, SUJAN TEEGALA SUDARSHAN
Entity Type:Individual
Prefix:DR
First Name:SUJAN TEEGALA
Middle Name:SUDARSHAN
Last Name:REDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4100
Mailing Address - Country:US
Mailing Address - Phone:479-314-5175
Mailing Address - Fax:479-314-3185
Practice Address - Street 1:7301 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4100
Practice Address - Country:US
Practice Address - Phone:479-314-5175
Practice Address - Fax:479-314-3185
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE128232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program