Provider Demographics
NPI:1386843811
Name:DIVEN, CONRAD FRANKLIN (MD)
Entity type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:FRANKLIN
Last Name:DIVEN
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 1:9250 N 3RD ST STE 3015
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2425
Mailing Address - Country:US
Mailing Address - Phone:602-633-3721
Mailing Address - Fax:602-595-1127
Practice Address - Street 1:13677 W MCDOWELL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:623-536-4200
Practice Address - Fax:623-882-4201
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-14
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ469672086S0102X, 2086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ901433Medicaid