Basic Information
| Provider Information | |||||||||
| NPI: | 1205848595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | TIYYAGURA | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2410 NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337612236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274990358 | ||||||||
| FaxNumber: | 7277813312 | ||||||||
| Practice Location | |||||||||
| Address1: | 7614 JACQUE RD STE B | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346677195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278632105 | ||||||||
| FaxNumber: | 7278622512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 01/19/2017 | ||||||||
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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 | 207RG0100X | ME40196 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 110012967 | 01 | RAILROAD MEDICARE | OTHER | 211156 | 01 | FL | AVMED | OTHER | 167251 | 01 | FL | WELLCARE | OTHER | 51256 | 01 | FL | BLUE CROS BLUE SHIELD | OTHER | 042172300 | 05 | FL | MEDICAID |