=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174058358
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAI SRIDHAR REDDY MALIREDDY M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2017
-----------------------------------------------------
Last Update Date | 10/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 KINGS HWY STE 340
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71103-3951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-8620
-----------------------------------------------------
Fax | 318-212-8625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 KINGS HWY STE 340
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71103-3951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-8620
-----------------------------------------------------
Fax | 318-212-8625
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 323330
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------