MEDICARE: ASHOK V KONDRU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	PT18475	ND
2	207RG0100X	Gastroenterology Physician	70312	WI
3	207RG0100X	Gastroenterology Physician	35063118	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	100004247	OTHER	OH	MEDICARE RR GROUP PTAN
4	9370811	OTHER	OH	MEDICARE GROUP
5	DG1495	OTHER	OH	MEDICARE RR GROUP#

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629054382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHOK V KONDRU M.D.

Provider Business Mailing Address
First Line	:	PO BOX 522
Second Line	:
City	:	ASHTABULA
State	:	OH
Zip	:	44005-0522
Country	:	US
Telephone Number	:	440-998-0322
Fax Number	:	440-998-4525

Provider Business Practice Location Address
First Line	:	2112 LAKE AVE
Second Line	:
City	:	ASHTABULA
State	:	OH
Zip	:	44004-3436
Country	:	US
Telephone Number	:	440-998-0322
Fax Number	:	440-998-4525

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	06/24/2022

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Directions to “ ASHOK V KONDRU M.D.” Practice Location

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