Basic Information
| Provider Information | |||||||||
| NPI: | 1508962176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | CHAKRAVARTHY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHAKRAVARTHY | ||||||||
| OtherFirstName: | SRINIVAS | ||||||||
| OtherMiddleName: | B | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4486 S GILEAD WAY | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841244016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016714803 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 26 N 1900 E | ||||||||
| Address2: | 701, WINTROBE BUILDING | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817806 | ||||||||
| FaxNumber: | 8015853355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 52163851205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 5216385-1205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 208M00000X | 5216385-1205 | UT | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RP1001X | 5216385-1205 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 1508962176 | 05 | UT | MEDICAID |