Healthcare Provider Details

I. General information

NPI: 1780835447
Provider Name (Legal Business Name): SRIDHAR KADUMPALLI REDDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12665 GARDEN GROVE BLVD STE 211
GARDEN GROVE CA
92843-1916
US

IV. Provider business mailing address

3401 N BROAD ST INTERNAL MEDICINE RESIDENCY OFFICE
PHILADELPHIA PA
19140-5103
US

V. Phone/Fax

Practice location:
  • Phone: 714-636-2890
  • Fax:
Mailing address:
  • Phone: 215-707-3397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA118770
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: