Healthcare Provider Details

I. General information

NPI: 1124519087
Provider Name (Legal Business Name): SHRAVAN G REDDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 09/25/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 LARKFIELD RD
EAST NORTHPORT NY
11731-4204
US

IV. Provider business mailing address

558 LARKFIELD RD
EAST NORTHPORT NY
11731-4204
US

V. Phone/Fax

Practice location:
  • Phone: 631-486-7459
  • Fax:
Mailing address:
  • Phone: 631-486-7459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number345008-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA11099300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: