Provider Demographics
NPI:1538152558
Name:JANI-KONDURI, NISHA B (OD)
Entity type:Individual
Prefix:DR
First Name:NISHA
Middle Name:B
Last Name:JANI-KONDURI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:1114 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3214
Practice Address - Country:US
Practice Address - Phone:847-895-7222
Practice Address - Fax:847-895-0861
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008796152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008796Medicaid
201905Medicare ID - Type Unspecified