Provider Demographics
NPI:1710034236
Name:KONICEK, ANNA GABRIELA (DO)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:GABRIELA
Last Name:KONICEK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ONNA
Other - Middle Name:GABRIELA
Other - Last Name:KONICEK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 11084
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81612-9659
Mailing Address - Country:US
Mailing Address - Phone:970-989-9597
Mailing Address - Fax:844-350-6556
Practice Address - Street 1:126 E HOMESTEAD DR
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-5033
Practice Address - Country:US
Practice Address - Phone:970-989-9597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY234719OtherSTATE LICENSE NUMBER
CO45287OtherCOLORADO STATE MEDICAL LICENSE
FLOS9734OtherSTATE LICENSE NUMBER
CA20A13552OtherSTATE MEDICAL LICENSE