Provider Demographics
NPI:1083687479
Name:GONZALEZ, CONRADO C JR (MD)
Entity Type:Individual
Prefix:
First Name:CONRADO
Middle Name:C
Last Name:GONZALEZ
Suffix:JR
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:PO BOX 31872
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-1872
Mailing Address - Country:US
Mailing Address - Phone:804-266-8717
Mailing Address - Fax:804-266-5677
Practice Address - Street 1:6105 HEALTH CENTER LANE
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407
Practice Address - Country:US
Practice Address - Phone:540-786-5262
Practice Address - Fax:540-786-5299
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010308382085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
226152OtherSOUTHERN HEALTH
1243459OtherCIGNA
3367933OtherAETNA
142595OtherANTHEM BCBS
396639OtherMAMSI
5407494OtherAETNA
226152OtherSOUTHERN HEALTH
396639OtherMAMSI
3367933OtherAETNA