Provider Demographics
NPI:1235154238
Name:CONRAD, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7316 NORMANDY DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-6712
Mailing Address - Country:US
Mailing Address - Phone:804-282-2612
Mailing Address - Fax:
Practice Address - Street 1:9901 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3357
Practice Address - Country:US
Practice Address - Phone:301-279-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062563146M00000X
VA0101035903207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1235154238Medicaid
VA235836OtherBLUE SHIELD
VA235837OtherBLUE SHIELD
VA1235154238Medicaid
VAVAA103381Medicare PIN
VA370001266Medicare PIN
VA235836OtherBLUE SHIELD