Provider Demographics
NPI:1235115692
Name:CONRAD, GEORGE T (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:T
Last Name:CONRAD
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:PO BOX 1022
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-1022
Mailing Address - Country:US
Mailing Address - Phone:301-588-0057
Mailing Address - Fax:301-588-0014
Practice Address - Street 1:8630 FENTON ST STE 122
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3803
Practice Address - Country:US
Practice Address - Phone:301-588-0057
Practice Address - Fax:301-588-0014
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD57785208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD004454700Medicaid
I45767Medicare UPIN
MDG02181C01Medicare ID - Type Unspecified