Healthcare Provider Details

I. General information

NPI: 1770646267
Provider Name (Legal Business Name): KALPANA KONDA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NEW BRUNSWICK AVE
PERTH AMBOY NJ
08861-3654
US

IV. Provider business mailing address

PO BOX 48270
NEWARK NJ
07101-4800
US

V. Phone/Fax

Practice location:
  • Phone: 732-293-2316
  • Fax: 732-324-3320
Mailing address:
  • Phone: 201-818-9118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA03869800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: