1972278042 NPI number — JOSEPH F CONDON, MD INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972278042 NPI number — JOSEPH F CONDON, MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPH F CONDON, MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1972278042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3417 TAMIAMI TRL STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33952-8158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-440-0380
Provider Business Mailing Address Fax Number:
877-349-5062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3417 TAMIAMI TRL STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-8158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-440-0380
Provider Business Practice Location Address Fax Number:
877-349-5062
Provider Enumeration Date:
08/11/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CONDON
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
941-626-5291

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ME148837 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 112756400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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