Provider Demographics
NPI:1629054382
Name:KONDRU, ASHOK V (MD)
Entity Type:Individual
Prefix:
First Name:ASHOK
Middle Name:V
Last Name:KONDRU
Suffix:
Gender:M
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 522
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44005-0522
Mailing Address - Country:US
Mailing Address - Phone:440-998-0322
Mailing Address - Fax:440-998-4525
Practice Address - Street 1:2112 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3436
Practice Address - Country:US
Practice Address - Phone:440-998-0322
Practice Address - Fax:440-998-4525
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPT18475207RG0100X
WI70312207RG0100X
OH35063118207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2803854Medicaid
OH0873210Medicaid
OH100004247OtherMEDICARE RR GROUP PTAN
OH9370811OtherMEDICARE GROUP
OHDG1495OtherMEDICARE RR GROUP#
0712343Medicare PIN
OH0873210Medicaid