MEDICARE: P. REDDY TUKIVAKALA, M.D., P.A.

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	261QP2300X	Primary Care Clinic/Center	R4048	AR

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	5B386	OTHER	AR	BLUE CROSS

General Provider Information

NPI Number	:	1689798449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P. REDDY TUKIVAKALA, M.D., P.A.

Provider Business Mailing Address
First Line	:	PO BOX 806
Second Line	:
City	:	HELENA
State	:	AR
Zip	:	72342-0806
Country	:	US
Telephone Number	:	870-338-7441
Fax Number	:	870-338-7945

Provider Business Practice Location Address
First Line	:	810 NEWMAN DR # A
Second Line	:
City	:	HELENA
State	:	AR
Zip	:	72342-8950
Country	:	US
Telephone Number	:	870-338-7441
Fax Number	:	870-338-7945

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. SHEILA A. PRIVETT
Credential	:
Telephone Number	:	870-338-7441

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/02/2009

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