Provider Demographics
NPI:1104979434
Name:MAKALA N. REDDY
Entity type:Organization
Organization Name:MAKALA N. REDDY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAKALA
Authorized Official - Middle Name:N
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-242-5116
Mailing Address - Street 1:18523 CORWIN RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2338
Mailing Address - Country:US
Mailing Address - Phone:760-242-5116
Mailing Address - Fax:760-242-5217
Practice Address - Street 1:18523 CORWIN RD
Practice Address - Street 2:SUITE F
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2338
Practice Address - Country:US
Practice Address - Phone:760-242-5116
Practice Address - Fax:760-242-5217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A326150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A326150Medicare ID - Type UnspecifiedSTATE LICENSE NUMBER
CAA26864Medicare UPIN