Basic Information
| Provider Information | |||||||||
| NPI: | 1659418119 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUDIBANDA | ||||||||
| FirstName: | RAGHUNATH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029696552 | ||||||||
| FaxNumber: | 5029693799 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 E BROADWAY STE 185E | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295455 | ||||||||
| FaxNumber: | 5026294151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 09/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 41448 | KY | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 2084N0400X | 41448 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 50021428 | 01 | KY | PASSPORT | OTHER | 3552164000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 000023033X | 01 | KY | HUMANA | OTHER | 000000587053 | 01 | KY | ANTHEM/NORTON | OTHER | 098231 | 01 | KY | SIHO | OTHER | 200948520 | 05 | IN | MEDICAID | 7100064020 | 05 | KY | MEDICAID |