Provider Demographics
NPI:1669424271
Name:CONRAD, GARY (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:CONRAD
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 1:3452 E FOOTHILL BLVD
Mailing Address - Street 2:STE 130
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-6006
Mailing Address - Country:US
Mailing Address - Phone:626-793-2885
Mailing Address - Fax:626-793-6262
Practice Address - Street 1:625 S FAIR OAKS AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2613
Practice Address - Country:US
Practice Address - Phone:626-793-4139
Practice Address - Fax:626-304-8280
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA58771207RH0005X
CAC37034207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RH0005XAllopathic & Osteopathic PhysiciansInternal MedicineHypertension Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C370340Medicaid
CAW2223OtherPTAN MEDICARE
CAW2223EOtherPTAN MEDICARE
CAW2223OtherPTAN MEDICARE
CA00C370340Medicaid
CAWC37034DMedicare PIN