Provider Demographics
NPI:1497263552
Name:THERESA M. CONYAC MD PLLC
Entity Type:Organization
Organization Name:THERESA M. CONYAC MD PLLC
Other - Org Name:GLOW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, MD
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONYAC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-722-2526
Mailing Address - Street 1:6705 HERITAGE PARKWAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-8749
Mailing Address - Country:US
Mailing Address - Phone:972-722-2526
Mailing Address - Fax:972-722-2528
Practice Address - Street 1:6705 HERITAGE PARKWAY
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-8749
Practice Address - Country:US
Practice Address - Phone:972-722-2526
Practice Address - Fax:972-722-2528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-11
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8875207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1598965188Medicaid