Healthcare Provider Details

I. General information

NPI: 1588613392
Provider Name (Legal Business Name): THOMAS R KONJOYAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 39TH ST
GROVES TX
77619-2905
US

IV. Provider business mailing address

122 GRAND CHASE DR
NEDERLAND TX
77627-4870
US

V. Phone/Fax

Practice location:
  • Phone: 409-719-7413
  • Fax:
Mailing address:
  • Phone: 409-719-7413
  • Fax: 409-724-0473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG2173
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: