Provider Demographics
NPI:1710966536
Name:KONDASH, MICHAEL L (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:KONDASH
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 1:790 NORTHERN BLVD
Mailing Address - Street 2:SUITE K
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-8799
Mailing Address - Country:US
Mailing Address - Phone:570-586-4141
Mailing Address - Fax:570-586-6722
Practice Address - Street 1:790 NORTHERN BLVD
Practice Address - Street 2:SUITE K
Practice Address - City:SOUTH ABINGTON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18411-8799
Practice Address - Country:US
Practice Address - Phone:570-586-4141
Practice Address - Fax:570-586-6722
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006653L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001440094Medicaid
PAE55511Medicare UPIN
PA179549Medicare PIN