Provider Demographics
NPI:1558402768
Name:CONYACK, DAVID (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:CONYACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:844-414-8291
Practice Address - Street 1:200 S ORANGE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5817
Practice Address - Country:US
Practice Address - Phone:197-332-7799
Practice Address - Fax:973-322-7791
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB06042200207LP2900X, 207L00000X, 208VP0000X, 208VP0014X
NJ25MB06042200207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7371101Medicaid
NJG56909Medicare UPIN
NJ000617CNKMedicare PIN