MEDICARE: DR. NISHA B JANI-KONDURI O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046008796	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538152558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NISHA B JANI-KONDURI O.D.

Provider Business Mailing Address
First Line	:	8614 WESTWOOD CENTER DR FL 9
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-2442
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:

Provider Business Practice Location Address
First Line	:	1114 W DEVON AVE
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3214
Country	:	US
Telephone Number	:	847-895-7222
Fax Number	:	847-895-0861

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	05/14/2024

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