Provider Demographics
NPI:1902111834
Name:MALLU REDDY MD INC
Entity Type:Organization
Organization Name:MALLU REDDY MD INC
Other - Org Name:REDDY CARE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MALLU
Authorized Official - Middle Name:CHENNA
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-623-4050
Mailing Address - Street 1:1196 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3027
Mailing Address - Country:US
Mailing Address - Phone:909-623-4050
Mailing Address - Fax:909-620-5259
Practice Address - Street 1:1196 N PARK AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3027
Practice Address - Country:US
Practice Address - Phone:909-623-4050
Practice Address - Fax:909-620-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A629580Medicaid
CAWA629581Medicare PIN
CA00A629580Medicare PIN
CA00A629580Medicaid