Provider Demographics
NPI:1588654008
Name:CONDO, ALLEN R (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:R
Last Name:CONDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3470
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:730 MALABAR RD STE B
Practice Address - Street 2:
Practice Address - City:MALABAR
Practice Address - State:FL
Practice Address - Zip Code:32950-3140
Practice Address - Country:US
Practice Address - Phone:321-409-6800
Practice Address - Fax:321-409-6810
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2018-11-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME72243207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32596ZOtherMEDICARE
FL080091871OtherRR MEDICARE
F54657Medicare UPIN
FL252018400Medicaid