Provider Demographics
NPI:1871576124
Name:REDDY, VODUR C (MD)
Entity type:Individual
Prefix:
First Name:VODUR
Middle Name:C
Last Name:REDDY
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 1:18400 US HIGHWAY 18
Mailing Address - Street 2:SUITE A
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2306
Mailing Address - Country:US
Mailing Address - Phone:760-242-3939
Mailing Address - Fax:
Practice Address - Street 1:18400 US HIGHWAY 18
Practice Address - Street 2:SUITE A
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2306
Practice Address - Country:US
Practice Address - Phone:760-242-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2012-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38271208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A382711Medicaid
CA00A382710Medicare ID - Type Unspecified
CA00A382711Medicaid
CACQ460ZMedicare PIN
CACQ460YMedicare PIN
CAA10088Medicare UPIN