Provider Demographics
NPI:1396766796
Name:CONRAD, EDWARD EVERETT JR (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:EVERETT
Last Name:CONRAD
Suffix:JR
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:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-0042
Mailing Address - Country:US
Mailing Address - Phone:503-635-5044
Mailing Address - Fax:503-635-3255
Practice Address - Street 1:550 3RD ST
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3002
Practice Address - Country:US
Practice Address - Phone:503-635-5044
Practice Address - Fax:503-635-3255
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC92424Medicare UPIN
OR000 BLBPCMedicare ID - Type Unspecified