Provider Demographics
NPI:1952379430
Name:MAITLAND, CONRAD CUTHBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:CUTHBERT
Last Name:MAITLAND
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 1:7441 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2123
Mailing Address - Country:US
Mailing Address - Phone:313-864-4452
Mailing Address - Fax:313-864-4469
Practice Address - Street 1:7441 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2123
Practice Address - Country:US
Practice Address - Phone:313-864-4452
Practice Address - Fax:313-864-4469
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI046953208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3296570Medicaid
MI3296570Medicaid
MIB45947Medicare UPIN