Provider Demographics
NPI:1891100368
Name:PESALA, SIVA PRASAD REDDY
Entity Type:Individual
Prefix:
First Name:SIVA PRASAD REDDY
Middle Name:
Last Name:PESALA
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 1:3803 EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-1116
Mailing Address - Country:US
Mailing Address - Phone:304-485-5041
Mailing Address - Fax:304-485-5678
Practice Address - Street 1:3803 EMERSON AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26104-1116
Practice Address - Country:US
Practice Address - Phone:304-485-5041
Practice Address - Fax:304-485-5678
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2023-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV327642084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014019434OtherMISSOURI TEMPORARY LICENSE