Healthcare Provider Details

I. General information

NPI: 1467452268
Provider Name (Legal Business Name): JOHN KENNETH CONRAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 W BURBANK BLVD
BURBANK CA
91505-2309
US

IV. Provider business mailing address

23025 SYLVAN ST
WOODLAND HILLS CA
91367-1629
US

V. Phone/Fax

Practice location:
  • Phone: 818-842-4400
  • Fax: 818-842-4401
Mailing address:
  • Phone: 818-558-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number31536
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA74574
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: