Provider Demographics
NPI:1487008884
Name:OFFICE OF SHERRY KONDZIELA, MD PLLC
Entity Type:Organization
Organization Name:OFFICE OF SHERRY KONDZIELA, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:KONDZIELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-921-4400
Mailing Address - Street 1:1307 8TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4137
Mailing Address - Country:US
Mailing Address - Phone:817-921-4400
Mailing Address - Fax:817-921-4406
Practice Address - Street 1:1307 8TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-921-4400
Practice Address - Fax:817-921-4406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-21
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3520208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX364011201Medicaid
TX00F5Z2OtherBCBS