Provider Demographics
NPI:1679707046
Name:DWARAKNATH P. REDDY, M.D.
Entity type:Organization
Organization Name:DWARAKNATH P. REDDY, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DWARAKNATH
Authorized Official - Middle Name:P
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-629-5540
Mailing Address - Street 1:811 E. 11TH STREET
Mailing Address - Street 2:SUITE 208
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4871
Mailing Address - Country:US
Mailing Address - Phone:909-629-5540
Mailing Address - Fax:
Practice Address - Street 1:1900 ROYALTY DR.
Practice Address - Street 2:SUITE 205
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3013
Practice Address - Country:US
Practice Address - Phone:909-629-5540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34093207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A340931Medicaid
CAA340930Medicare PIN
CA00A340931Medicaid