Provider Demographics
NPI:1255370201
Name:REDDY, MARYADA SRINIVAS (M D)
Entity type:Individual
Prefix:
First Name:MARYADA
Middle Name:SRINIVAS
Last Name:REDDY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-4159
Mailing Address - Country:US
Mailing Address - Phone:972-283-2389
Mailing Address - Fax:972-283-2473
Practice Address - Street 1:310 E HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-4159
Practice Address - Country:US
Practice Address - Phone:972-283-2389
Practice Address - Fax:972-283-2473
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4103207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157739702Medicaid
TX157739701Medicaid
TX8G3321OtherBLUE CROSS BLUE SHIELD
TXG76906Medicare UPIN
TX157739702Medicaid
TX8320B7Medicare PIN
TX157739701Medicaid