Provider Demographics
NPI:1740485275
Name:REDDY, SURAJ GOPAL (MD)
Entity type:Individual
Prefix:DR
First Name:SURAJ
Middle Name:GOPAL
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 1:610 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2372
Mailing Address - Country:US
Mailing Address - Phone:505-225-2500
Mailing Address - Fax:505-225-2025
Practice Address - Street 1:610 BROADWAY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2372
Practice Address - Country:US
Practice Address - Phone:505-225-2500
Practice Address - Fax:505-225-2025
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0565207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9537161OtherMEDIARE RR
NMNM300836OtherBCBS