Basic Information
| Provider Information | |||||||||
| NPI: | 1376540187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | PRATHIMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5365 W ATLANTIC AVE STE 504 | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334848194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612419300 | ||||||||
| FaxNumber: | 5612419339 | ||||||||
| Practice Location | |||||||||
| Address1: | 6821 NW 11TH PL | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523313353 | ||||||||
| FaxNumber: | 3523339035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | ME76862 | FL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208VP0000X | ME76862 | FL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 2081P2900X | ME76862 | FL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 255169100 | 05 | FL | MEDICAID |