Provider Demographics
NPI:1235140542
Name:CONWAY, RICHARD GARY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GARY
Last Name:CONWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5572
Mailing Address - Country:US
Mailing Address - Phone:347-820-0380
Mailing Address - Fax:
Practice Address - Street 1:1445 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5572
Practice Address - Country:US
Practice Address - Phone:347-820-0380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123809207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00581411Medicaid
NYA62042Medicare UPIN
NY00581411Medicaid