Healthcare Provider Details

I. General information

NPI: 1245715804
Provider Name (Legal Business Name): KONSTANTIN BRNJOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2018
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-2909
US

IV. Provider business mailing address

PO BOX 103450
GAINESVILLE FL
32610-3450
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-8017
  • Fax:
Mailing address:
  • Phone: 352-265-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: