Provider Demographics
NPI:1336933530
Name:BODDI REDDY, DHEERAJ (MD)
Entity type:Individual
Prefix:
First Name:DHEERAJ
Middle Name:
Last Name:BODDI REDDY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6631 N GREENWICH PL
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-6616
Mailing Address - Country:US
Mailing Address - Phone:312-608-9890
Mailing Address - Fax:312-608-9890
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:855-673-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
90200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program