Healthcare Provider Details

I. General information

NPI: 1700847142
Provider Name (Legal Business Name): RAJENDER REDDY JINNA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

682 UNION AVE LONG ISLAND FQHC, INC.
WESTBURY NY
11590-3552
US

IV. Provider business mailing address

380 NASSAU RD LONG ISLAND FQHC, INC.
ROOSEVELT NY
11575-1343
US

V. Phone/Fax

Practice location:
  • Phone: 516-571-9535
  • Fax:
Mailing address:
  • Phone: 516-571-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number186081
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: