Provider Demographics
NPI:1104112770
Name:KONOPACK, SITHA (MD)
Entity type:Individual
Prefix:DR
First Name:SITHA
Middle Name:
Last Name:KONOPACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SITHA
Other - Middle Name:RAO
Other - Last Name:MANGIPUDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3003
Mailing Address - Country:US
Mailing Address - Phone:352-265-5911
Mailing Address - Fax:352-265-5606
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610
Practice Address - Country:US
Practice Address - Phone:352-265-5911
Practice Address - Fax:352-265-5606
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN16312390200000X
FLME118690207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012921200Medicaid
FL012921200Medicaid