Basic Information
| Provider Information | |||||||||
| NPI: | 1053576058 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | PREETHAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D.,C.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 N NEVADA AVE | ||||||||
| Address2: | SUITE 4007 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197768500 | ||||||||
| FaxNumber: | 7196341448 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 N NEVADA AVE | ||||||||
| Address2: | SUITE 4007 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197768500 | ||||||||
| FaxNumber: | 7196341448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2008 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | DR.0053625 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | 53625 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 79526217 | 05 | CO | MEDICAID |