Basic Information
| Provider Information | |||||||||
| NPI: | 1508898818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | CHANDRA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | S2845 WHITE EAGLE RD | ||||||||
| Address2: | HO-CHUNK HOUSES OF WELLNESS | ||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083550251 | ||||||||
| FaxNumber: | 6083559643 | ||||||||
| Practice Location | |||||||||
| Address1: | S2845 WHITE EAGLE RD | ||||||||
| Address2: | HO-CHUNK HOUSE OF WELLNESS | ||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083550251 | ||||||||
| FaxNumber: | 6083559643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 03/07/2012 | ||||||||
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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 | 207RE0101X | MD00043121 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 47052-20 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 8432320 | 05 | WA | MEDICAID |