Provider Demographics
NPI:1063673812
Name:GONDI, AVANTICA (MD)
Entity Type:Individual
Prefix:DR
First Name:AVANTICA
Middle Name:
Last Name:GONDI
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 1:1818 HARDEN BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1812
Mailing Address - Country:US
Mailing Address - Phone:863-210-5640
Mailing Address - Fax:863-210-5716
Practice Address - Street 1:1818 HARDEN BLVD STE 120
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1813
Practice Address - Country:US
Practice Address - Phone:863-210-5640
Practice Address - Fax:863-210-5716
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 104474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001481700Medicaid