Provider Demographics
NPI:1265810691
Name:CONRAD, MARK (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CONRAD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CLARA BARTON BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-5738
Mailing Address - Country:US
Mailing Address - Phone:469-800-2260
Mailing Address - Fax:
Practice Address - Street 1:601 CLARA BARTON BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5738
Practice Address - Country:US
Practice Address - Phone:469-800-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR8878207Q00000X
ARE-11892207Q00000X
ND15482207Q00000X
OK6550207Q00000X
MO2019000361207Q00000X
LA312293207Q00000X
ALDO.2059207Q00000X
MTMED-PHYS-LIC-78315207Q00000X
UT11418132-1204207Q00000X
MDH88113207Q00000X
MEDO2975207Q00000X
AZ008193207Q00000X
NVDO2502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine