Provider Demographics
NPI:1740473263
Name:AUDREY KONOW M.D. A PROFESSIONAL CORP
Entity type:Organization
Organization Name:AUDREY KONOW M.D. A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KONOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-961-8500
Mailing Address - Street 1:5150 E LA PALMA AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-2085
Mailing Address - Country:US
Mailing Address - Phone:714-975-1507
Mailing Address - Fax:714-340-0606
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:714-340-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32179207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0004110236OtherAETNA
CA1659481125OtherINDIVIDUAL NPI
CA00G321790OtherBLUE SHIELD CA
CA00G321790OtherMEDI-CAL
CA0004110236OtherAETNA
CA00G321790OtherMEDI-CAL