Provider Demographics
NPI:1306995865
Name:REDD, DEIDRE D (MD)
Entity type:Individual
Prefix:
First Name:DEIDRE
Middle Name:D
Last Name:REDD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ASSOCIATION DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1298
Mailing Address - Country:US
Mailing Address - Phone:304-388-1724
Mailing Address - Fax:304-388-1721
Practice Address - Street 1:501 MORRIS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1326
Practice Address - Country:US
Practice Address - Phone:304-388-5432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073959R208100000X
WV31368208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2140874Medicaid
OH000000228201OtherANTHEM
OH2140874Medicaid
OH4058942Medicare PIN
OH4058947Medicare PIN
OH000000228201OtherANTHEM
OHH30984Medicare UPIN
OH4040572Medicare PIN
4040573Medicare PIN
OH4040573Medicare PIN