Healthcare Provider Details

I. General information

NPI: 1275616526
Provider Name (Legal Business Name): MONTA LAVAE CONRAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FORBES STREET SUITE 200
ANNAPOLIS MD
21401
US

IV. Provider business mailing address

200 FORBES STREET SUITE 200
ANNAPOLIS MD
21401
US

V. Phone/Fax

Practice location:
  • Phone: 410-263-6363
  • Fax: 410-263-4086
Mailing address:
  • Phone: 410-263-6363
  • Fax: 410-263-4086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD33125
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD63209
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: