Basic Information
| Provider Information | |||||||||
| NPI: | 1386620870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | PRASANTHI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHAMAKURA | ||||||||
| OtherFirstName: | PRASANTHI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4788 HODGES BLVD | ||||||||
| Address2: | BUILDING B, SUITE 108 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322247222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042239100 | ||||||||
| FaxNumber: | 9042239282 | ||||||||
| Practice Location | |||||||||
| Address1: | 4788 HODGES BLVD | ||||||||
| Address2: | BUILDING B, SUITE 108 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322247222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042239100 | ||||||||
| FaxNumber: | 9042239282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 11/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | ME91195 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | ME9115 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 273107000 | 05 | FL | MEDICAID |