Provider Demographics
NPI:1336124023
Name:KONDRO, ERIC F (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:F
Last Name:KONDRO
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 1:340 KELLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3811
Mailing Address - Country:US
Mailing Address - Phone:573-582-1234
Mailing Address - Fax:573-582-1212
Practice Address - Street 1:1225 AGUILAR DRIVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361
Practice Address - Country:US
Practice Address - Phone:573-582-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109389207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208113605Medicaid