Provider Demographics
NPI:1891061040
Name:PETROV-KONDRATOV, VADIM (MD)
Entity type:Individual
Prefix:MR
First Name:VADIM
Middle Name:
Last Name:PETROV-KONDRATOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W OGLETHORPE HWY
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4415
Mailing Address - Country:US
Mailing Address - Phone:912-910-3777
Mailing Address - Fax:912-292-0005
Practice Address - Street 1:604 W OGLETHORPE HWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4415
Practice Address - Country:US
Practice Address - Phone:912-910-3777
Practice Address - Fax:912-292-0005
Is Sole Proprietor?:No
Enumeration Date:2012-03-31
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE10674208VP0014X
GA88065208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine