Healthcare Provider Details

I. General information

NPI: 1205455003
Provider Name (Legal Business Name): KONRAD EDWARD SURDEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2020
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WAHOO AVE
GROTON CT
06349-2324
US

IV. Provider business mailing address

1 WAHOO AVE
GROTON CT
06349-2324
US

V. Phone/Fax

Practice location:
  • Phone: 401-841-4475
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0102206848
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: