Provider Demographics
NPI:1639673601
Name:KONJA, ANTHONY THAYER (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:THAYER
Last Name:KONJA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28655 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-4105
Mailing Address - Country:US
Mailing Address - Phone:586-393-1330
Mailing Address - Fax:586-393-1308
Practice Address - Street 1:28655 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4105
Practice Address - Country:US
Practice Address - Phone:586-393-1330
Practice Address - Fax:586-393-1308
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101026440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program