Healthcare Provider Details

I. General information

NPI: 1114244845
Provider Name (Legal Business Name): SHANTHI G REDDY MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 S MAIN ST
LUMBERTON TX
77657-7390
US

IV. Provider business mailing address

1233 S MAIN ST
LUMBERTON TX
77657-7390
US

V. Phone/Fax

Practice location:
  • Phone: 409-755-3600
  • Fax: 409-755-4443
Mailing address:
  • Phone: 409-755-3600
  • Fax: 409-755-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ3587
License Number StateTX

VIII. Authorized Official

Name: DR. SHANTHI G REDDY
Title or Position: PHYSICIAN
Credential: MD PA
Phone: 409-755-3600