Provider Demographics
NPI:1831324334
Name:DIVAKAR KRISHNAREDDY MD INC
Entity Type:Organization
Organization Name:DIVAKAR KRISHNAREDDY MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIVAKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISHNAREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-435-9049
Mailing Address - Street 1:120 S MONTEBELLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4730
Mailing Address - Country:US
Mailing Address - Phone:661-435-9049
Mailing Address - Fax:323-443-3601
Practice Address - Street 1:120 S MONTEBELLO BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4730
Practice Address - Country:US
Practice Address - Phone:661-435-9049
Practice Address - Fax:323-443-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35665207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1871538710OtherPERSONAL NPI