=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851609739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEEPIKA REDDY NALLALA M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2010
-----------------------------------------------------
Last Update Date | 01/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 N STATE OF FRANKLIN RD FL 2
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-6092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-439-7280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 699
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37684-0699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-302-6882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | MD468743
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 036127090
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 54984
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------