Basic Information
| Provider Information | |||||||||
| NPI: | 1649384892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | PRADEEP | ||||||||
| MiddleName: | GOPALA | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3412 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Practice Location | |||||||||
| Address1: | 3412 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 036110081 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208000000X | 036110081 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.