Provider Demographics
NPI:1033374715
Name:SCHOENWALD, CONRAD FREDERIC (DO)
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:FREDERIC
Last Name:SCHOENWALD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 E MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3009
Mailing Address - Country:US
Mailing Address - Phone:707-469-4640
Mailing Address - Fax:707-449-3919
Practice Address - Street 1:1119 E MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3009
Practice Address - Country:US
Practice Address - Phone:707-469-4640
Practice Address - Fax:707-449-3919
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247534207Q00000X
CA20A11262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1033374715Medicaid
MO1033374715Medicaid