Provider Demographics
NPI:1598449860
Name:DANIEL, CONRAD JOSEPH
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:JOSEPH
Last Name:DANIEL
Suffix:
Gender:M
Credentials:
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:5255 E STOP 11 RD STE 300
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6341
Practice Address - Country:US
Practice Address - Phone:317-528-4723
Practice Address - Fax:317-528-4699
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10004307A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant