Provider Demographics
NPI:1942205653
Name:REDDY, GAUTHAM P (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTHAM
Middle Name:P
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2135 N COLLECTIVE LN
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3560
Mailing Address - Country:US
Mailing Address - Phone:316-261-3220
Mailing Address - Fax:316-261-3298
Practice Address - Street 1:2135 N COLLECTIVE LN
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3560
Practice Address - Country:US
Practice Address - Phone:316-261-3220
Practice Address - Fax:316-261-3298
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-29594204R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100419060BMedicaid
KSH58555Medicare UPIN
KS104971Medicare PIN