Provider Demographics
NPI:1699762997
Name:CONRAD, KENNETH ANDREW (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ANDREW
Last Name:CONRAD
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 1:877 ARTHUR MOORE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-9510
Mailing Address - Country:US
Mailing Address - Phone:904-282-2385
Mailing Address - Fax:
Practice Address - Street 1:881 USS JAMES MADISON RD
Practice Address - Street 2:NAVAL BRANCH HEALTH CLINIC
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547-2531
Practice Address - Country:US
Practice Address - Phone:912-573-8801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-02
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 72302207Q00000X
IN01029429A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine