Healthcare Provider Details

I. General information

NPI: 1760093678
Provider Name (Legal Business Name): DR. SERGEY M KONDRASHOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. SERGUEI M KONDRACHOV

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 BURNS AVE
LAKE WALES FL
33853-3314
US

IV. Provider business mailing address

6548 TIMBER SHORES RD
LAKE WALES FL
33898-9061
US

V. Phone/Fax

Practice location:
  • Phone: 863-679-3338
  • Fax:
Mailing address:
  • Phone: 337-442-3899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ9514
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: