Provider Demographics
NPI:1346686185
Name:VIJAY KONDA MD PA
Entity Type:Organization
Organization Name:VIJAY KONDA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:K
Authorized Official - Last Name:KONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-207-2560
Mailing Address - Street 1:2338 IMMOKALEE RD
Mailing Address - Street 2:SUITE 183
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1445
Mailing Address - Country:US
Mailing Address - Phone:904-207-2560
Mailing Address - Fax:
Practice Address - Street 1:3447 PINE RIDGE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-3927
Practice Address - Country:US
Practice Address - Phone:904-207-2560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96103207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty