Provider Demographics
NPI:1659418119
Name:GUDIBANDA, RAGHUNATH (MD)
Entity Type:Individual
Prefix:
First Name:RAGHUNATH
Middle Name:
Last Name:GUDIBANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-969-6552
Mailing Address - Fax:502-969-3799
Practice Address - Street 1:315 E BROADWAY STE 185E
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-629-5455
Practice Address - Fax:502-629-4151
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41448208VP0000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50021428OtherPASSPORT
KY3552164000OtherPASSPORT ADVANTAGE
KY000023033XOtherHUMANA
KY000000587053OtherANTHEM/NORTON
KY098231OtherSIHO
IN200948520Medicaid
KY7100064020Medicaid
KY000000587053OtherANTHEM/NORTON