Provider Demographics
NPI:1003897919
Name:CONRAD, TERESA L (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2031
Mailing Address - Country:US
Mailing Address - Phone:321-843-8164
Mailing Address - Fax:407-389-5312
Practice Address - Street 1:83 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2031
Practice Address - Country:US
Practice Address - Phone:321-843-8164
Practice Address - Fax:407-389-5312
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67035207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376137100Medicaid
FLF90368Medicare UPIN
FL26150Medicare ID - Type Unspecified