Healthcare Provider Details

I. General information

NPI: 1972620250
Provider Name (Legal Business Name): KAMESWARI SURYA KONDURI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 KINWEST PKWY SUITE 100
IRVING TX
75063-3409
US

IV. Provider business mailing address

2300 SOUTHERN OAK DR
IRVING TX
75063-3489
US

V. Phone/Fax

Practice location:
  • Phone: 972-401-0545
  • Fax: 972-401-0614
Mailing address:
  • Phone: 972-444-9626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberM2678
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: