Healthcare Provider Details

I. General information

NPI: 1841552338
Provider Name (Legal Business Name): DEEPIKA REDDY RALLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

9552 ROCHEL DR
SHREVEPORT LA
71115-3854
US

V. Phone/Fax

Practice location:
  • Phone: 860-986-4098
  • Fax: 507-607-8545
Mailing address:
  • Phone: 860-986-4098
  • Fax: 507-607-8545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.206394
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD12345
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberMD.206394
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: