Healthcare Provider Details

I. General information

NPI: 1457761223
Provider Name (Legal Business Name): KRISHNA KONAKONDLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 ROUTE 70 E STE A
CHERRY HILL NJ
08034-2408
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 856-375-6240
  • Fax: 856-375-6241
Mailing address:
  • Phone: 856-355-0340
  • Fax: 856-355-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA10196700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: