Provider Demographics
NPI:1508838707
Name:KONDZIELA, SHERRY R (MD)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:R
Last Name:KONDZIELA
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:PO BOX 733332
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3332
Mailing Address - Country:US
Mailing Address - Phone:817-284-9850
Mailing Address - Fax:817-284-3425
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
Practice Address - Country:US
Practice Address - Phone:817-284-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3520208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128454909Medicaid
TX848661OtherBCBS
TX250004927Medicare PIN
TX848661Medicare PIN
TX128454905Medicaid