Provider Demographics
NPI:1861685844
Name:REDDIVARI, VENKATA R (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATA
Middle Name:R
Last Name:REDDIVARI
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:PO BOX 14657
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33766-4657
Mailing Address - Country:US
Mailing Address - Phone:727-797-6768
Mailing Address - Fax:
Practice Address - Street 1:2810 W SAINT ISABEL ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6375
Practice Address - Country:US
Practice Address - Phone:813-873-7479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116695207RN0300X
LAMD.205218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009448300Medicaid
FL009448300Medicaid