Provider Demographics
NPI:1578553483
Name:WITTRAM, CONRAD (MBCHB)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:
Last Name:WITTRAM
Suffix:
Gender:M
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E FRONT AVE
Mailing Address - Street 2:SUITE 502
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2701
Mailing Address - Country:US
Mailing Address - Phone:208-415-0556
Mailing Address - Fax:208-292-3130
Practice Address - Street 1:601 E FRONT AVE
Practice Address - Street 2:SUITE 502
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2701
Practice Address - Country:US
Practice Address - Phone:208-415-0556
Practice Address - Fax:208-292-3130
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2081562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology