Basic Information
| Provider Information | |||||||||
| NPI: | 1437163441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | VIVEK | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6102 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949486102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158843404 | ||||||||
| FaxNumber: | 4158830877 | ||||||||
| Practice Location | |||||||||
| Address1: | 5176 HILL RD E | ||||||||
| Address2: | |||||||||
| City: | LAKEPORT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954536300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072625030 | ||||||||
| FaxNumber: | 7072563508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 04/20/2017 | ||||||||
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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 | 2085R0202X | A82747 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A827470 | 05 | CA | MEDICAID |