Provider Demographics
NPI:1922002450
Name:REDDY, MUDDASANI V (MD)
Entity Type:Individual
Prefix:
First Name:MUDDASANI
Middle Name:V
Last Name:REDDY
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 1:12573 DURBIN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:129 N 8TH ST
Practice Address - Street 2:
Practice Address - City:EAST ST LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-2917
Practice Address - Country:US
Practice Address - Phone:618-482-7242
Practice Address - Fax:314-810-1399
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL92933/818070Medicare ID - Type UnspecifiedMEDICARE #/GROUP #