Provider Demographics
NPI:1497761241
Name:CONERLY, DONALD V (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:V
Last Name:CONERLY
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-705-2897
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:50 PARKWAY LN
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-3035
Practice Address - Country:US
Practice Address - Phone:601-705-2897
Practice Address - Fax:601-584-6457
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1558930OtherAMERICAN ADMIN GROUP
LA1782271Medicaid
MS00016765Medicaid
012920837OtherRAILROAD MEDICARE
MS1558930OtherAMERICAN ADMIN GROUP
MS082945533Medicare PIN