Provider Demographics
NPI:1992817522
Name:REDDY, RENUKA (MD)
Entity type:Individual
Prefix:DR
First Name:RENUKA
Middle Name:
Last Name:REDDY
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 1:401 GRAND OAK LN
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9430
Mailing Address - Country:US
Mailing Address - Phone:606-439-4484
Mailing Address - Fax:606-439-0575
Practice Address - Street 1:1908 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-2505
Practice Address - Country:US
Practice Address - Phone:606-439-2662
Practice Address - Fax:606-439-0575
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64073984Medicaid
KYH90492Medicare UPIN
KY0501420Medicare ID - Type Unspecified