Healthcare Provider Details

I. General information

NPI: 1760823595
Provider Name (Legal Business Name): KALYAN CHAKRAVARTHY DADIREDDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-0846
US

IV. Provider business mailing address

PO BOX 100138
GAINESVILLE FL
32610-0138
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8670
  • Fax:
Mailing address:
  • Phone: 352-273-8670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number126832
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number54391
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME155911
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME155911
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: