Provider Demographics
NPI:1679564132
Name:REDDY, JYOTHSNA M (MD)
Entity type:Individual
Prefix:
First Name:JYOTHSNA
Middle Name:M
Last Name:REDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3508
Mailing Address - Country:US
Mailing Address - Phone:763-287-6543
Mailing Address - Fax:763-287-6544
Practice Address - Street 1:5502 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3508
Practice Address - Country:US
Practice Address - Phone:763-287-6543
Practice Address - Fax:763-287-6544
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4640000400Medicaid
MNF09101Medicare UPIN