Healthcare Provider Details

I. General information

NPI: 1053997742
Provider Name (Legal Business Name): ARCHANA M REDDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 10/30/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11980 SAN VICENTE BLVD SUITE 102
LOS ANGELES CA
90049-5012
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-208-7777
  • Fax: 310-445-8709
Mailing address:
  • Phone: 310-301-5138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA191979
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: