Provider Demographics
NPI:1225196777
Name:CONRAD, TIMMIE JOE (MD)
Entity Type:Individual
Prefix:
First Name:TIMMIE
Middle Name:JOE
Last Name:CONRAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:CONRAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6015
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-0015
Mailing Address - Country:US
Mailing Address - Phone:502-899-7778
Mailing Address - Fax:502-897-5757
Practice Address - Street 1:204 BRECKENRIDGE LANE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-899-7778
Practice Address - Fax:502-897-5757
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29088207W00000X
IN01041184207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64290885Medicaid
KY64290885Medicaid