Provider Demographics
NPI:1245291186
Name:REDDY, PANNALA VIJAY (MD)
Entity type:Individual
Prefix:MRS
First Name:PANNALA
Middle Name:VIJAY
Last Name:REDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:P
Other - Middle Name:VIJAY
Other - Last Name:REDDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:510 S SYCAMORE ST
Mailing Address - Street 2:STE D
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803
Mailing Address - Country:US
Mailing Address - Phone:804-861-6888
Mailing Address - Fax:804-863-0672
Practice Address - Street 1:510 S SYCAMORE ST
Practice Address - Street 2:STE D
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803
Practice Address - Country:US
Practice Address - Phone:804-861-6888
Practice Address - Fax:804-863-0672
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029372207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6274609Medicaid
VA6274609Medicaid
160000112Medicare PIN
160000112Medicare ID - Type Unspecified