Healthcare Provider Details

I. General information

NPI: 1255591103
Provider Name (Legal Business Name): SUBHADRA CHEREDDY MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LAND GRANT ST STE 6
SAINT AUGUSTINE FL
32092-2262
US

IV. Provider business mailing address

130 LAND GRANT ST STE 6
SAINT AUGUSTINE FL
32092-2262
US

V. Phone/Fax

Practice location:
  • Phone: 904-999-4684
  • Fax: 904-436-5064
Mailing address:
  • Phone: 904-999-4684
  • Fax: 904-436-5064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME160972
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: