Provider Demographics
NPI:1366498206
Name:CONWAY, STAFFORD AUSTIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:STAFFORD
Middle Name:AUSTIN
Last Name:CONWAY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:STAFFORD
Other - Middle Name:A
Other - Last Name:CONWAY
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:410 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 135
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6971
Mailing Address - Country:US
Mailing Address - Phone:423-431-2350
Mailing Address - Fax:423-431-2372
Practice Address - Street 1:410 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 135
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6971
Practice Address - Country:US
Practice Address - Phone:423-431-2350
Practice Address - Fax:423-431-2372
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM79192084N0400X
WAMD603002342084N0400X
OH35C.0003322084N0400X
TN552732084N0400X, 208M00000X
ORMD2138412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
I47030Medicare UPIN
I47030Medicare UPIN
AL051557080Medicare ID - Type Unspecified