Provider Demographics
NPI:1013910801
Name:CONDOS, WILLIAM R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:CONDOS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 OAK PARK BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8990
Mailing Address - Country:US
Mailing Address - Phone:337-494-3278
Mailing Address - Fax:337-494-3240
Practice Address - Street 1:1717 OAK PARK BLVD
Practice Address - Street 2:FL 2
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8990
Practice Address - Country:US
Practice Address - Phone:337-494-3278
Practice Address - Fax:337-494-3240
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08677R207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1915823Medicaid
LAE86706Medicare UPIN
LA5N535F942Medicare PIN