MEDICARE: JAYASANKAR K REDDY MD

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	207R00000X	Internal Medicine Physician	N6404	TX
2	207RN0300X	Nephrology Physician	N6404	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174562276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAYASANKAR K REDDY MD

Provider Business Mailing Address
First Line	:	4412 KELL BLVD
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76309-4719
Country	:	US
Telephone Number	:	940-716-0557
Fax Number	:	940-355-0028

Provider Business Practice Location Address
First Line	:	4412 KELL BLVD
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76309-4719
Country	:	US
Telephone Number	:	940-716-0557
Fax Number	:	940-355-0028

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

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	02/06/2023

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