Healthcare Provider Details

I. General information

NPI: 1124091343
Provider Name (Legal Business Name): PETE E KONDOLIOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 NILES CORTLAND RD NE
WARREN OH
44484-1974
US

IV. Provider business mailing address

321 NILES CORTLAND RD NE
WARREN OH
44484-1974
US

V. Phone/Fax

Practice location:
  • Phone: 330-609-5588
  • Fax: 330-609-5740
Mailing address:
  • Phone: 330-609-5588
  • Fax: 330-609-5740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-06-1915-K
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: