Basic Information
| Provider Information | |||||||||
| NPI: | 1780678706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONDOVSKI | ||||||||
| FirstName: | SACHO | ||||||||
| MiddleName: | RADE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1095 MARSHALL WAY | ||||||||
| Address2: | STE 100,201,202,203 | ||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956675722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306262920 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 28780 SINGLE OAK DR | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925903625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516764193 | ||||||||
| FaxNumber: | 9517191469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A6077 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 20A6077 | 01 | CA | LICENSE | OTHER | BK2783377 | 01 | CA | DEA | OTHER |