Provider Demographics
NPI:1003253964
Name:CONEYBEARE, DI FAN (MD)
Entity Type:Individual
Prefix:
First Name:DI
Middle Name:FAN
Last Name:CONEYBEARE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DI
Other - Middle Name:
Other - Last Name:FAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:622 W 168TH ST # VC260
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:760-808-2557
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:760-808-2557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY282317-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program