Basic Information
| Provider Information | |||||||||
| NPI: | 1427023878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | VIJAYA | ||||||||
| MiddleName: | LINGA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VIJAYA | ||||||||
| OtherFirstName: | LINGA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7163323525 | ||||||||
| Practice Location | |||||||||
| Address1: | 16 4TH ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MALONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129531340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184812801 | ||||||||
| FaxNumber: | 5184812689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 05/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 19957 | NC | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 122167 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 85084 | 01 | NC | BCNC | OTHER | 8985084 | 05 | NC | MEDICAID | 201586B | 01 | NC | PSC MEDICARE PROVIDER # | OTHER |