Healthcare Provider Details

I. General information

NPI: 1568858603
Provider Name (Legal Business Name): NITIN JOHN KONDAMUDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 MCDONALD RD
TYLER TX
75701-5934
US

IV. Provider business mailing address

2608 MCDONALD RD
TYLER TX
75701-5934
US

V. Phone/Fax

Practice location:
  • Phone: 903-595-5514
  • Fax: 903-262-3715
Mailing address:
  • Phone: 903-595-5514
  • Fax: 903-262-3715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberR6220
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: