Healthcare Provider Details

I. General information

NPI: 1225122039
Provider Name (Legal Business Name): RAVITA REDDY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VISTA CLINIC 17053 E FOOTHILL BLVD
FONTANA CA
92335
US

IV. Provider business mailing address

PO BOX 54252
IRVINE CA
92619-4252
US

V. Phone/Fax

Practice location:
  • Phone: 909-347-1300
  • Fax:
Mailing address:
  • Phone: 949-413-0753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA85458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: