Provider Demographics
NPI:1699783613
Name:REDDY, BANDA P (MD)
Entity type:Individual
Prefix:
First Name:BANDA
Middle Name:P
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:25195 KELLY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4909
Mailing Address - Country:US
Mailing Address - Phone:586-775-4594
Mailing Address - Fax:586-775-4506
Practice Address - Street 1:25195 KELLY RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4909
Practice Address - Country:US
Practice Address - Phone:586-775-4594
Practice Address - Fax:586-775-4506
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-09-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301032390207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0615038941OtherBLUE CROSS BLUE SHIELD
MI1189553Medicaid
MID91414Medicare UPIN
MI1503894Medicare ID - Type Unspecified