Healthcare Provider Details

I. General information

NPI: 1659418119
Provider Name (Legal Business Name): RAGHUNATH GUDIBANDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E BROADWAY STE 185E
LOUISVILLE KY
40202-3700
US

IV. Provider business mailing address

PO BOX 950202
LOUISVILLE KY
40295-0202
US

V. Phone/Fax

Practice location:
  • Phone: 502-629-5455
  • Fax: 502-629-4151
Mailing address:
  • Phone: 502-969-6552
  • Fax: 502-969-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number41448
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number41448
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: