Provider Demographics
NPI:1891711909
Name:LALLA-REDDY, SUJATA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUJATA
Middle Name:
Last Name:LALLA-REDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:REDDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 11629
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-5036
Mailing Address - Country:US
Mailing Address - Phone:714-968-6789
Mailing Address - Fax:714-202-2626
Practice Address - Street 1:11180 WARNER AVE STE 353
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7516
Practice Address - Country:US
Practice Address - Phone:714-968-6789
Practice Address - Fax:714-202-2626
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75875207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A758750Medicaid
CAG87583Medicare UPIN
CA00A758750Medicaid