Provider Demographics
NPI:1033130174
Name:FONDAK, ALEXANDER ALBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:ALBERT
Last Name:FONDAK
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:866-630-9882
Mailing Address - Fax:920-689-4149
Practice Address - Street 1:804 S BERKLEY RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5198
Practice Address - Country:US
Practice Address - Phone:765-457-4455
Practice Address - Fax:765-457-0056
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032543A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INA61967Medicare UPIN
INFO363860Medicare ID - Type Unspecified
IN100136810AMedicaid