Provider Demographics
NPI:1871538710
Name:KRISHNAREDDY, DIVAKAR (MD)
Entity type:Individual
Prefix:DR
First Name:DIVAKAR
Middle Name:
Last Name:KRISHNAREDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 SATURN AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4568
Mailing Address - Country:US
Mailing Address - Phone:323-587-3965
Mailing Address - Fax:
Practice Address - Street 1:16702 VALLEY VIEW AVE
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-5824
Practice Address - Country:US
Practice Address - Phone:562-921-0341
Practice Address - Fax:562-404-0266
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35665207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A356650Medicaid
CAWA356651Medicare ID - Type Unspecified
CA00A356650Medicaid