Provider Demographics
NPI:1174515084
Name:REDDY, KAVITHA R (MD)
Entity type:Individual
Prefix:DR
First Name:KAVITHA
Middle Name:R
Last Name:REDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 S LINDEN RD STE A
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3428
Mailing Address - Country:US
Mailing Address - Phone:810-230-1210
Mailing Address - Fax:810-230-1225
Practice Address - Street 1:1311 S LINDEN RD STE A
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3428
Practice Address - Country:US
Practice Address - Phone:810-230-1210
Practice Address - Fax:810-230-1225
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085040208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI17429OtherM-CARE
MI4781201Medicaid
MIP00279740OtherRAILROAD MEDICARE
0-523-377-0OtherECFMG #
MI142459OtherCARE CHOICES-PREFERRED
MI25050OtherBLUE CARE NETWORK
MO2005005836OtherSTATE LICENSE
MIKR085040OtherBCBSM
MIKR085040OtherBCBSM
MII42884Medicare UPIN