Provider Demographics
NPI:1376759316
Name:P KONDA MD PA
Entity Type:Organization
Organization Name:P KONDA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-798-5500
Mailing Address - Street 1:13005 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 145
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-9206
Mailing Address - Country:US
Mailing Address - Phone:561-798-5500
Mailing Address - Fax:561-795-3341
Practice Address - Street 1:13005 SOUTHERN BLVD
Practice Address - Street 2:SUITE 145
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9206
Practice Address - Country:US
Practice Address - Phone:561-798-5500
Practice Address - Fax:561-795-3341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. PRASAD KONDA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43981174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD70658Medicare UPIN
FLK0570Medicare ID - Type Unspecified