Basic Information
| Provider Information | |||||||||
| NPI: | 1396131835 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | VIVEK | ||||||||
| MiddleName: | VANKAYALA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 SHERBURNE LN | ||||||||
| Address2: | |||||||||
| City: | WESTFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018861176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783192260 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4201 SAINT ANTOINE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455146 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2015 | ||||||||
| LastUpdateDate: | 04/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.