Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0207X | Pediatric Hematology-Oncologist | 53522 | AZ |
NPI | 1073851150 |
---|---|
Provider Name | Naresh Reddivalla |
First Address | Mesa, AZ 85202-4768 |
Second Address | Mesa, AZ 85202-4769 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2013 |
Last Update Date | 22/10/2020 |