Provider Demographics
NPI:1306983515
Name:CONRAD, JOHN J (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:CONRAD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16761 ST. CLAIR AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-9400
Mailing Address - Country:US
Mailing Address - Phone:330-386-9313
Mailing Address - Fax:330-386-9353
Practice Address - Street 1:16761 ST. CLAIR AVE
Practice Address - Street 2:SUITE I
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9400
Practice Address - Country:US
Practice Address - Phone:330-386-9313
Practice Address - Fax:330-386-9353
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3525152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0472368Medicaid
OH0511253Medicare ID - Type Unspecified
OH0472368Medicaid
OH34-1349490Medicare UPIN