Healthcare Provider Details

I. General information

NPI: 1386843811
Provider Name (Legal Business Name): CONRAD FRANKLIN DIVEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2007
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13677 W MCDOWELL RD SUITE 201
GOODYEAR AZ
85395
US

IV. Provider business mailing address

9250 N 3RD ST STE 3015
PHOENIX AZ
85020-2425
US

V. Phone/Fax

Practice location:
  • Phone: 623-536-4200
  • Fax: 623-882-4201
Mailing address:
  • Phone: 602-633-3721
  • Fax: 602-595-1127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number46967
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number46967
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number46967
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: