Provider Demographics
NPI:1679565881
Name:CONRAD, NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
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 1:3000 N UNIVERSITY DR
Mailing Address - Street 2:SUITE K
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5055
Mailing Address - Country:US
Mailing Address - Phone:954-752-2630
Mailing Address - Fax:954-752-0183
Practice Address - Street 1:3000 N UNIVERSITY DR
Practice Address - Street 2:SUITE K
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5055
Practice Address - Country:US
Practice Address - Phone:954-752-2630
Practice Address - Fax:954-752-0183
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-110873207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00116900OtherRAILROAD MEDICARE
ILK05746Medicare PIN
ILP00116900OtherRAILROAD MEDICARE
ILI04070Medicare UPIN