Provider Demographics
NPI:1821058470
Name:JEEREDDI, PRASAD ANJANEYA (MD)
Entity Type:Individual
Prefix:
First Name:PRASAD
Middle Name:ANJANEYA
Last Name:JEEREDDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEEREDDI
Other - Middle Name:ANJANEYA
Other - Last Name:PRASAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1488
Practice Address - Street 1:1904 N ORANGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3008
Practice Address - Country:US
Practice Address - Phone:909-469-1823
Practice Address - Fax:909-469-1827
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32129207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A321290Medicaid
A87607Medicare UPIN
CA00A321290Medicaid
CAAU940ZMedicare PIN
CABN910ZMedicare PIN