Basic Information
| Provider Information | |||||||||
| NPI: | 1104051515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONDA | ||||||||
| FirstName: | SAILESH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4037 NW 86TH TER | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326069277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525941942 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4037 NW 86TH TER | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326069277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525941942 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2009 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | ME125090 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | ME125090 | FL | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207NS0135X | ME125090 | FL | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 015594200 | 05 | FL | MEDICAID |