Provider Demographics
NPI:1891890620
Name:REDDY, GOPAL (MD)
Entity Type:Individual
Prefix:
First Name:GOPAL
Middle Name:
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARGARET
Other - Middle Name:
Other - Last Name:MORESHEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:500 WALTER NE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102
Mailing Address - Country:US
Mailing Address - Phone:505-842-5518
Mailing Address - Fax:505-247-8509
Practice Address - Street 1:500 WALTER NE
Practice Address - Street 2:SUITE 204
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-842-5518
Practice Address - Fax:505-247-8509
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM772372086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09449Medicaid
NM09449Medicaid