Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 164820 | NY |
NPI | 1003800533 |
---|---|
Provider Name | Michael Conrad |
First Address | Brooklyn, NY 11209-3802 |
Second Address | Brooklyn, NY 11209-3802 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A63541 | (02) | NY |