Provider Demographics
NPI:1700828068
Name:KONOPKA, JOHN (OT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KONOPKA
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 EMERSON DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5291
Mailing Address - Country:US
Mailing Address - Phone:843-424-1690
Mailing Address - Fax:
Practice Address - Street 1:485 EMERSON DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-5291
Practice Address - Country:US
Practice Address - Phone:843-424-1690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2472225100000X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1581Medicaid