Provider Demographics
NPI:1578504262
Name:CONRAD, DIANE K (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1681
Mailing Address - Country:US
Mailing Address - Phone:419-636-4517
Mailing Address - Fax:419-636-6438
Practice Address - Street 1:442 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1681
Practice Address - Country:US
Practice Address - Phone:419-636-4517
Practice Address - Fax:419-636-6438
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045372207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080042254OtherRAILROAD
OH0478460Medicaid
OH0489802Medicare PIN