Provider Demographics
NPI:1871804757
Name:REDDY, DHEERAJ (MD)
Entity type:Individual
Prefix:DR
First Name:DHEERAJ
Middle Name:
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 1:1055 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3436
Mailing Address - Country:US
Mailing Address - Phone:414-479-2300
Mailing Address - Fax:
Practice Address - Street 1:1055 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-479-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69635-20207RH0003X, 207R00000X
TXT5443207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100078539Medicaid