Provider Demographics
NPI:1477727451
Name:DECONDA, DEEPTHI (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPTHI
Middle Name:
Last Name:DECONDA
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 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:1030 PRESIDENT AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5923
Practice Address - Country:US
Practice Address - Phone:508-235-6349
Practice Address - Fax:508-973-1715
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD14439207RG0100X
MA254999207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110096466AMedicaid
RIDD93883Medicaid
RIDD93883Medicaid
MA003042901Medicare PIN