Healthcare Provider Details

I. General information

NPI: 1497917744
Provider Name (Legal Business Name): ADITYA REDDY BODDU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16261 BASS RD STE 300
FORT MYERS FL
33908-3671
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-6410
  • Fax: 239-343-4014
Mailing address:
  • Phone: 239-343-6410
  • Fax: 239-343-4014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME143336
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01068916A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME143336
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: