Healthcare Provider Details

I. General information

NPI: 1114205838
Provider Name (Legal Business Name): CHIRANJEEVI PRAMODNATH REDDY SIDDAGUNTA MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2123 AUBURN AVE STE 440
CINCINNATI OH
45219-2906
US

IV. Provider business mailing address

2123 AUBURN AVE STE 440
CINCINNATI OH
45219-2906
US

V. Phone/Fax

Practice location:
  • Phone: 513-648-8980
  • Fax: 513-648-8988
Mailing address:
  • Phone: 513-648-8980
  • Fax: 513-648-8988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-44640
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License NumberMD-44640
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number35.C000357
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: