=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083610703
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAGADEESH C REDDY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2005
-----------------------------------------------------
Last Update Date | 11/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31852 COAST HWY STE 201
-----------------------------------------------------
City | LAGUNA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92651-6765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-715-0505
-----------------------------------------------------
Fax | 949-715-0508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25467 NELLIE GAIL RD
-----------------------------------------------------
City | LAGUNA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92653-6306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-521-6060
-----------------------------------------------------
Fax | 949-521-6063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A82683
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | A82683
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | ME88635
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | A82683
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------