Healthcare Provider Details

I. General information

NPI: 1497142889
Provider Name (Legal Business Name): PRADEEP REDDY KATHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date: 12/03/2015
Reactivation Date: 01/06/2016

III. Provider practice location address

2400 UNSER BLVD SE STE 19100
RIO RANCHO NM
87124-4740
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-224-7000
  • Fax: 313-745-4052
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD2021-0943
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: