Healthcare Provider Details

I. General information

NPI: 1780104901
Provider Name (Legal Business Name): BRYAN MARK CONDER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BRIDGE ST STE 201
DANVILLE VA
24541-1222
US

IV. Provider business mailing address

142 S MAIN ST
DANVILLE VA
24541-2922
US

V. Phone/Fax

Practice location:
  • Phone: 434-799-4488
  • Fax: 434-773-6977
Mailing address:
  • Phone: 434-799-2248
  • Fax: 434-799-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0116030468
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: