Healthcare Provider Details

I. General information

NPI: 1225250129
Provider Name (Legal Business Name): RAVI KUDUMULA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11115 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-672-6400
  • Fax: 260-672-6459
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43609
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number43609
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01075277A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: