Healthcare Provider Details

I. General information

NPI: 1144725052
Provider Name (Legal Business Name): MRUDU HERBERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2018
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE STE L404
LEXINGTON KY
40536-0293
US

IV. Provider business mailing address

800 ROSE ST RM MN-118
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5643
  • Fax: 859-323-3795
Mailing address:
  • Phone: 859-323-6183
  • Fax: 859-323-6183

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 Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number55491
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: