Provider Demographics
NPI:1053393983
Name:IKONDU, DESMOND OKEY (MD)
Entity type:Individual
Prefix:
First Name:DESMOND
Middle Name:OKEY
Last Name:IKONDU
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 1:2502 W TRENTON RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-8070
Mailing Address - Country:US
Mailing Address - Phone:956-630-2119
Mailing Address - Fax:956-682-6115
Practice Address - Street 1:2502 W TRENTON RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-8070
Practice Address - Country:US
Practice Address - Phone:956-630-2119
Practice Address - Fax:956-682-6115
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1348207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141660402Medicaid
TX141060401Medicaid
TX141660401OtherINDIV TPI MEDICIAID
TX201528101OtherGROUP TPI MEDICIAID
TX00Z798OtherMEDICARE PTAN -5/1/08
TX0075GCOtherBCBS
TX141660405Medicaid
TX113464OtherSUPERIOR HEALTH CARE
TX141660407Medicaid
TXH30251Medicare UPIN
TX00714MMedicare PIN
TX8C8264Medicare PIN
TX141660401OtherINDIV TPI MEDICIAID
TX00Z798OtherMEDICARE PTAN -5/1/08