Basic Information
| Provider Information | |||||||||
| NPI: | 1821058470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEEREDDI | ||||||||
| FirstName: | PRASAD | ||||||||
| MiddleName: | ANJANEYA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRASAD | ||||||||
| OtherFirstName: | JEEREDDI | ||||||||
| OtherMiddleName: | ANJANEYA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 840 TOWNE CENTER DR | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093981550 | ||||||||
| FaxNumber: | 9093981488 | ||||||||
| Practice Location | |||||||||
| Address1: | 1904 N ORANGE GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094691823 | ||||||||
| FaxNumber: | 9094691827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
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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 | 207R00000X | A32129 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | A32129 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 00A321290 | 05 | CA | MEDICAID |