Healthcare Provider Details

I. General information

NPI: 1881218535
Provider Name (Legal Business Name): MYTHILI KANTHI GUDIPATI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 BALL PARK RD
HARLAN KY
40831-1701
US

IV. Provider business mailing address

490 WOODLAND HLS
HARLAN KY
40831-2565
US

V. Phone/Fax

Practice location:
  • Phone: 606-573-8100
  • Fax:
Mailing address:
  • Phone: 989-327-2498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number58819
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: