Basic Information
| Provider Information | |||||||||
| NPI: | 1487728739 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONDRU | ||||||||
| FirstName: | JAISHEELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3643 N ROXBORO ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194708490 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3643 N ROXBORO ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194708490 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2008-00121 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2008-00121 | NC | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0066524 | 05 | SC | MEDICAID | 0066524 | 05 | NJ | MEDICAID | 5908824 | 05 | NC | MEDICAID |