Healthcare Provider Details

I. General information

NPI: 1639968779
Provider Name (Legal Business Name): REVATHI KUDITHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 NORTH BOULEVARD BRG MID CITY MEDICINE CLINIC SUITE 130
BATON ROUGE LA
70806
US

IV. Provider business mailing address

3401 NORTH BOULEVARD SUITE 130, BRG MID CITY MEDICINE C
BATON ROUGE LA
70806
US

V. Phone/Fax

Practice location:
  • Phone: 225-287-7900
  • Fax:
Mailing address:
  • Phone: 225-387-7900
  • Fax: 225-442-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: