Provider Demographics
NPI:1669437174
Name:CONDARAS, MICHAEL R (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:CONDARAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:R
Other - Last Name:CONDARAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1202 VIRGINIA ST. E.
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2909
Mailing Address - Country:US
Mailing Address - Phone:304-342-3323
Mailing Address - Fax:
Practice Address - Street 1:1202 VIRGINIA ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2909
Practice Address - Country:US
Practice Address - Phone:304-342-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV161111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0131291000Medicaid
WVCO 0383813Medicare ID - Type Unspecified
WV0131291000Medicaid