Provider Demographics
NPI:1386620870
Name:REDDY, PRASANTHI (MD)
Entity type:Individual
Prefix:DR
First Name:PRASANTHI
Middle Name:
Last Name:REDDY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:PRASANTHI
Other - Middle Name:
Other - Last Name:CHAMAKURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4788 HODGES BLVD
Mailing Address - Street 2:BUILDING B, SUITE 108
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-7222
Mailing Address - Country:US
Mailing Address - Phone:904-223-9100
Mailing Address - Fax:904-223-9282
Practice Address - Street 1:4788 HODGES BLVD
Practice Address - Street 2:BUILDING B, SUITE 108
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-7222
Practice Address - Country:US
Practice Address - Phone:904-223-9100
Practice Address - Fax:904-223-9282
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME911952080A0000X
FLME9115208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273107000Medicaid