Provider Demographics
NPI:1063486488
Name:KONDZIOLKA, DOUGLAS S (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:S
Last Name:KONDZIOLKA
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 1:530 1ST AVE
Mailing Address - Street 2:SUITE 8R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-2950
Mailing Address - Fax:
Practice Address - Street 1:530 1ST AVE
Practice Address - Street 2:SUITE 8R
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267044207T00000X
PAMD042521L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001269761Medicaid
PA001269761Medicaid
PAF15135Medicare UPIN