Provider Demographics
NPI:1881218535
Name:GUDIPATI, MYTHILI KANTHI
Entity Type:Individual
Prefix:
First Name:MYTHILI KANTHI
Middle Name:
Last Name:GUDIPATI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 WOODLAND HLS
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-2565
Mailing Address - Country:US
Mailing Address - Phone:989-327-2498
Mailing Address - Fax:
Practice Address - Street 1:81 BALL PARK RD
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-1701
Practice Address - Country:US
Practice Address - Phone:606-573-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY58819207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program