Basic Information
| Provider Information | |||||||||
| NPI: | 1366702870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONDOWE | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | VAUGHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375TH MEDICAL GROUP | ||||||||
| Address2: | 310 W LOSEY ST | ||||||||
| City: | SCOTT AIR FORCE BASE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622255250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182569355 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 375TH MEDICAL GROUP | ||||||||
| Address2: | 310W LOSEY ST | ||||||||
| City: | SCOTT AFB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182567799 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2012 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 0101255760 | VA | N | Allopathic & Osteopathic Physicians | General Practice | 208M00000X | 036139867 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 036139867 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1366702870 | 05 | TX | MEDICAID |