Provider Demographics
NPI:1720074602
Name:EDWARDS-CONRAD, PENELOPE (MD)
Entity Type:Individual
Prefix:DR
First Name:PENELOPE
Middle Name:
Last Name:EDWARDS-CONRAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PENELOPE
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3338 COUNTRY CLUB RD STE L
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7425
Mailing Address - Country:US
Mailing Address - Phone:229-244-1191
Mailing Address - Fax:229-244-1195
Practice Address - Street 1:2935 N ASHLEY ST
Practice Address - Street 2:D116
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1777
Practice Address - Country:US
Practice Address - Phone:229-244-1192
Practice Address - Fax:229-244-1195
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2010-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA452052084N0400X
FLME739412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00813062BMedicaid
13BDDGZMedicare PIN
G33512Medicare UPIN