Basic Information
| Provider Information | |||||||||
| NPI: | 1659510337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YELLU | ||||||||
| FirstName: | MAHENDER | ||||||||
| MiddleName: | REDDY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4371 VERONICA S SHOEMAKER BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339162216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1396 WHISPER CIR | ||||||||
| Address2: | |||||||||
| City: | SEBRING | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338701204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633851244 | ||||||||
| FaxNumber: | 8633856086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2009 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 53779-20 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35-121453 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0000X | ME137058 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | ME137058 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 100006909 | 05 | WI | MEDICAID |