Provider Demographics
NPI:1649219874
Name:CONLEY, GARY L (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:CONLEY
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 1:2451 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1893
Mailing Address - Country:US
Mailing Address - Phone:937-208-7377
Mailing Address - Fax:937-208-7375
Practice Address - Street 1:2451 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1893
Practice Address - Country:US
Practice Address - Phone:937-208-7377
Practice Address - Fax:937-208-7375
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.064270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0980765Medicaid
OH0763384Medicare PIN
OH0980765Medicaid
OH0763385Medicare PIN