Healthcare Provider Details

I. General information

NPI: 1497368336
Provider Name (Legal Business Name): EDWARD KONDROT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2020
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15230 LAKESHORE DR
CLEARLAKE CA
95422-8107
US

IV. Provider business mailing address

15230 LAKESHORE DR
CLEARLAKE CA
95422-8107
US

V. Phone/Fax

Practice location:
  • Phone: 707-995-4518
  • Fax: 707-995-4526
Mailing address:
  • Phone: 707-995-4518
  • Fax: 707-995-4526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD021475E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG89041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: