Provider Demographics
NPI:1427011840
Name:CONWAY, LAURENCE A (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:A
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 1:170 GOVERNORS AVENUE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155
Mailing Address - Country:US
Mailing Address - Phone:781-395-4909
Mailing Address - Fax:781-395-5081
Practice Address - Street 1:170 GOVERNORS AVENUE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:781-395-4909
Practice Address - Fax:781-395-5081
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75448207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
F97313Medicare UPIN
J30992Medicare ID - Type Unspecified