Provider Demographics
NPI:1962470617
Name:REDDY, VIMAL A (DPM)
Entity Type:Individual
Prefix:DR
First Name:VIMAL
Middle Name:A
Last Name:REDDY
Suffix:
Gender:M
Credentials:DPM
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:8075 GATE PKWY W
Mailing Address - Street 2:SUITE 301
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3684
Mailing Address - Country:US
Mailing Address - Phone:904-739-9129
Mailing Address - Fax:904-739-9127
Practice Address - Street 1:8075 GATE PKWY W
Practice Address - Street 2:SUITE 301
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-3684
Practice Address - Country:US
Practice Address - Phone:904-739-9129
Practice Address - Fax:904-739-9127
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPO3091213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6330940002Medicare NSC
FLU7234ZMedicare PIN
FL5727950001Medicare NSC