Provider Demographics
NPI:1063417996
Name:REDDY, PRAMOD A (MD)
Entity type:Individual
Prefix:DR
First Name:PRAMOD
Middle Name:A
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:606-528-8661
Practice Address - Street 1:45 MOONBOW PLZ
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8949
Practice Address - Country:US
Practice Address - Phone:606-523-9010
Practice Address - Fax:606-523-5923
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29557207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP01427298OtherRR MEDICARE
KYK000751OtherMEDICARE PTAN
KY64295579Medicaid
KYK000751OtherMEDICARE PTAN
KY0662501Medicare ID - Type Unspecified