Provider Demographics
NPI:1245667294
Name:KONDO, KORETADA (MD)
Entity type:Individual
Prefix:DR
First Name:KORETADA
Middle Name:
Last Name:KONDO
Suffix:
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 1:50 BURROUGHS RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06612-1410
Mailing Address - Country:US
Mailing Address - Phone:203-610-4652
Mailing Address - Fax:
Practice Address - Street 1:50 BURROUGHS RD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:CT
Practice Address - Zip Code:06612-1410
Practice Address - Country:US
Practice Address - Phone:203-610-4652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-07
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT013732207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology