Provider Demographics
NPI:1942278221
Name:REDDY, MALLU C (MD)
Entity Type:Individual
Prefix:
First Name:MALLU
Middle Name:C
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 1:1196 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3027
Mailing Address - Country:US
Mailing Address - Phone:909-623-4050
Mailing Address - Fax:909-620-5259
Practice Address - Street 1:1196 N PARK AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3027
Practice Address - Country:US
Practice Address - Phone:909-623-4050
Practice Address - Fax:909-620-5259
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62958207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A629580Medicaid
CAG55885Medicare UPIN
CAWA62958IMedicare PIN
CA110167876Medicare PIN
CA00A629580Medicare PIN