Basic Information
| Provider Information | |||||||||
| NPI: | 1053372177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | NAGENDRA | ||||||||
| MiddleName: | PRASAD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9677 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841099677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665007071 | ||||||||
| FaxNumber: | 8665007081 | ||||||||
| Practice Location | |||||||||
| Address1: | 894 E 3900 S | ||||||||
| Address2: | #B | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841072151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665007071 | ||||||||
| FaxNumber: | 8665007081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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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 | 207R00000X | 2005020847 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 6369024-1205 | UT | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 6369024-1205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6369024-1205 | 01 | UT | UTAH DOPL | OTHER | 6369024-8905 | 01 | UT | UTAH DOPL CS | OTHER | 208331801 | 05 | MO | MEDICAID |