Provider Demographics
NPI:1710221742
Name:DALTON, CONRAD IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:IVAN
Last Name:DALTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 S. SHAWNEE RIDGE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77382-2555
Mailing Address - Country:US
Mailing Address - Phone:281-757-6081
Mailing Address - Fax:281-681-2772
Practice Address - Street 1:98 S. SHAWNEE RIDGE CIRCLE
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77382-2555
Practice Address - Country:US
Practice Address - Phone:281-757-6081
Practice Address - Fax:281-681-2772
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD69982083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine