1558586537 NPI number — MISS MARTINA DIANE KONDAS DPT

Table of content: MISS MARTINA DIANE KONDAS DPT (NPI 1558586537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558586537 NPI number — MISS MARTINA DIANE KONDAS DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONDAS
Provider First Name:
MARTINA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558586537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 629
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAULDIN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29662-0629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-836-7003
Provider Business Mailing Address Fax Number:
843-836-7004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11251 ROUTE 322
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHIPPENVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16254-4933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-221-5390
Provider Business Practice Location Address Fax Number:
814-393-6544
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  11566 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT016467 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1014338240001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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