Healthcare Provider Details

I. General information

NPI: 1821139684
Provider Name (Legal Business Name): PRAKRUTI REDDY JAMBULA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3827 BROOKMERE PL
MASON OH
45040-3029
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-3149
  • Fax:
Mailing address:
  • Phone: 513-435-3989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.091930
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number35.091930
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: