Provider Demographics
NPI:1336259266
Name:RAJU, REVATHY (MD)
Entity Type:Individual
Prefix:DR
First Name:REVATHY
Middle Name:
Last Name:RAJU
Suffix:
Gender:F
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:DEPT 5090 PO BOX 740041
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-7441
Mailing Address - Country:US
Mailing Address - Phone:502-451-9949
Mailing Address - Fax:502-451-4553
Practice Address - Street 1:231 E CHESTNUT ST
Practice Address - Street 2:KOSAIR CHILDRENS HOSPITAL
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1821
Practice Address - Country:US
Practice Address - Phone:502-451-9949
Practice Address - Fax:502-451-4553
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25155207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64251556Medicaid
KY0215603Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE ID
KY64251556Medicaid