Basic Information
| Provider Information | |||||||||
| NPI: | 1376998930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONDA | ||||||||
| FirstName: | SHIREESHA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | KONDA | ||||||||
| OtherFirstName: | SHIREESHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2705 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358042705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626538802 | ||||||||
| FaxNumber: | 2562653886 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 SIVLEY RD SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562653880 | ||||||||
| FaxNumber: | 2562653886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2016 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 38712 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.