Provider Demographics
NPI:1144284233
Name:REDDY, YASODHARA MADHAVA (MD)
Entity type:Individual
Prefix:
First Name:YASODHARA
Middle Name:MADHAVA
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 1:3420 22ND PLACE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:4102 24TH ST
Practice Address - Street 2:SUITE 507
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1806
Practice Address - Country:US
Practice Address - Phone:806-725-7750
Practice Address - Fax:806-723-7518
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8639208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135946509Medicaid
TXTXB120717Medicare PIN
TX135946509Medicaid