Provider Demographics
NPI:1285642421
Name:CONWAY, BERNARD (OD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:
Last Name:CONWAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11805 NW CEDAR FALLS DR
Mailing Address - Street 2:STE 105
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-2776
Mailing Address - Country:US
Mailing Address - Phone:503-474-0265
Mailing Address - Fax:503-530-8648
Practice Address - Street 1:11805 NW CEDAR FALLS DR
Practice Address - Street 2:STE 105
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-2776
Practice Address - Country:US
Practice Address - Phone:503-747-0265
Practice Address - Fax:503-530-8648
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2182T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR038120Medicaid
OR06436Medicare UPIN