Provider Demographics
NPI:1851358477
Name:REDDY, PRATHYUSHA KETHI (MD)
Entity Type:Individual
Prefix:
First Name:PRATHYUSHA
Middle Name:KETHI
Last Name:REDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRATHYUSHA
Other - Middle Name:
Other - Last Name:KETHIREDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:14131 MIDWAY RD
Mailing Address - Street 2:SUITE 620
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3623
Mailing Address - Country:US
Mailing Address - Phone:972-249-0200
Mailing Address - Fax:972-249-0206
Practice Address - Street 1:14131 MIDWAY RD
Practice Address - Street 2:SUITE 620
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3623
Practice Address - Country:US
Practice Address - Phone:972-249-0200
Practice Address - Fax:972-249-0206
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164235701Medicaid
TX164235702Medicaid
TX164235702Medicaid
TX8G1030Medicare PIN
I03990Medicare UPIN
TX8B7996Medicare ID - Type Unspecified