Provider Demographics
NPI:1063763506
Name:KORKONDA, KAMAL KISHORE
Entity type:Individual
Prefix:MR
First Name:KAMAL
Middle Name:KISHORE
Last Name:KORKONDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7128 MOUNTAIN SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80927-4001
Mailing Address - Country:US
Mailing Address - Phone:303-803-4960
Mailing Address - Fax:
Practice Address - Street 1:7128 MOUNTAIN SPRUCE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80927-4001
Practice Address - Country:US
Practice Address - Phone:303-803-4960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11683OtherPHYSICAL THERAPY LICENSE