Basic Information
| Provider Information | |||||||||
| NPI: | 1962664011 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONIKKARA | ||||||||
| FirstName: | JOHN JOSEPH | ||||||||
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| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8157 SOUTHWESTERN BLVD | ||||||||
| Address2: | APARTMENT# 142 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752062019 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1615 DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604147800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 04/10/2017 | ||||||||
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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 | 2084P0800X | MD60704069 | WA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084N0400X | MD60704069 | WA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084S0012X | MD60704069 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2070508 | 05 | WA | MEDICAID |