Provider Demographics
NPI:1952406852
Name:CONRAD, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8505 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4621
Mailing Address - Country:US
Mailing Address - Phone:703-970-2600
Mailing Address - Fax:
Practice Address - Street 1:8505 ARLINGTON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4621
Practice Address - Country:US
Practice Address - Phone:703-970-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246217174400000X
CAA68279174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101246217OtherSTATE LICENSE
CAA68279OtherSTATE LICENSE