Provider Demographics
NPI:1598449860
Name:DANIEL, CONRAD JOSEPH
Entity type:Individual
Prefix:
First Name:CONRAD
Middle Name:JOSEPH
Last Name:DANIEL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E CRAGMONT DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-4834
Mailing Address - Country:US
Mailing Address - Phone:317-437-9880
Mailing Address - Fax:
Practice Address - Street 1:1230 E CRAGMONT DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-4834
Practice Address - Country:US
Practice Address - Phone:317-437-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10004307A363A00000X
ORPA224057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant