Healthcare Provider Details

I. General information

NPI: 1609181452
Provider Name (Legal Business Name): DEEPTI REDDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-4466
  • Fax: 551-996-0969
Mailing address:
  • Phone: 551-996-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD.206424
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25MA11455800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier05501847
Identifier TypeMEDICAID
Identifier StateMS
Identifier Issuer
# 2
Identifier2341316
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: