Provider Demographics
NPI:1649559592
Name:REDDY, MADAN MOHAN GANGAPURAM (MD)
Entity type:Individual
Prefix:DR
First Name:MADAN MOHAN
Middle Name:GANGAPURAM
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 1:1210 KY HIGHWAY 36 E STE G3
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-7498
Mailing Address - Country:US
Mailing Address - Phone:859-234-3605
Mailing Address - Fax:859-234-5666
Practice Address - Street 1:1210 KY HIGHWAY 36 E STE 1D
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-7490
Practice Address - Country:US
Practice Address - Phone:859-234-1707
Practice Address - Fax:859-234-1768
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48934207X00000X
WV24976207X00000X
MN105688207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100227130Medicaid