Provider Demographics
NPI:1174562276
Name:REDDY, JAYASANKAR K (MD)
Entity type:Individual
Prefix:
First Name:JAYASANKAR
Middle Name:K
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAYASANKAR
Other - Middle Name:R
Other - Last Name:KALUVAPALLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4412 KELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4719
Mailing Address - Country:US
Mailing Address - Phone:940-716-0557
Mailing Address - Fax:940-355-0028
Practice Address - Street 1:4412 KELL BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4719
Practice Address - Country:US
Practice Address - Phone:940-716-0557
Practice Address - Fax:940-355-0028
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6404207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213626901Medicaid
TX213626902Medicaid
TXTXB155473Medicare PIN
TX213626901Medicaid
TXTXB155472Medicare PIN
TXTXB104434Medicare PIN
TXP00847940Medicare PIN