MEDICARE: DIVYA REDDY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	41675	TX

General Provider Information

NPI Number	:	1043109119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVYA REDDY

Provider Business Mailing Address
First Line	:	401 WESTINGHOUSE RD APT 10108
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-5617
Country	:	US
Telephone Number	:	612-512-3963
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 CARLOS G PARKER BLVD NW STE 108
Second Line	:
City	:	TAYLOR
State	:	TX
Zip	:	76574-7059
Country	:	US
Telephone Number	:	254-978-5928
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2025
Last Update Date	:	07/02/2025

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Directions to “ DIVYA REDDY ” Practice Location

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