Provider Demographics
NPI:1659481125
Name:KONOW, AUDREY M (MD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:M
Last Name:KONOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E YORBA LINDA BLVD
Mailing Address - Street 2:STE 1
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3006
Mailing Address - Country:US
Mailing Address - Phone:714-961-8500
Mailing Address - Fax:
Practice Address - Street 1:5150 E LA PALMA AVE STE 106
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-2085
Practice Address - Country:US
Practice Address - Phone:714-975-1507
Practice Address - Fax:714-463-4393
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG32179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G321790Medicaid
C36033Medicare UPIN
CAG32179Medicare ID - Type UnspecifiedMEDICARE NHIC