Provider Demographics
NPI:1063418630
Name:REDDY, MOOLA PRABHAKAR (MD)
Entity type:Individual
Prefix:MR
First Name:MOOLA
Middle Name:PRABHAKAR
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:M
Other - Middle Name:P
Other - Last Name:REDDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8865 BELLA TERRA PL
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-8850
Mailing Address - Country:US
Mailing Address - Phone:916-960-9724
Mailing Address - Fax:
Practice Address - Street 1:1528 EUREKA RD STE 103
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3047
Practice Address - Country:US
Practice Address - Phone:916-772-5325
Practice Address - Fax:916-772-6333
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36428208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFI429AMedicare PIN