Provider Demographics
NPI:1710246038
Name:KONDA, SRINIVAS
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:KONDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7004 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48210-2872
Mailing Address - Country:US
Mailing Address - Phone:313-554-3600
Mailing Address - Fax:313-554-3601
Practice Address - Street 1:7004 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-2872
Practice Address - Country:US
Practice Address - Phone:313-554-3600
Practice Address - Fax:313-554-3601
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist