Provider Demographics
NPI:1053576058
Name:REDDY, PREETHAM (MD,CM)
Entity type:Individual
Prefix:
First Name:PREETHAM
Middle Name:
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD,CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 N NEVADA AVE
Mailing Address - Street 2:SUITE 4007
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6819
Mailing Address - Country:US
Mailing Address - Phone:719-776-8500
Mailing Address - Fax:719-634-1448
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:SUITE 4007
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6819
Practice Address - Country:US
Practice Address - Phone:719-776-8500
Practice Address - Fax:719-634-1448
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-20
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0053625207R00000X
390200000X
CO53625207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79526217Medicaid
CO79526217Medicaid