Provider Demographics
NPI:1699845867
Name:CONAWAY, EARL EDWIN JR (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:EDWIN
Last Name:CONAWAY
Suffix:JR
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 1:1198 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-1636
Mailing Address - Country:US
Mailing Address - Phone:740-432-6012
Mailing Address - Fax:740-435-8552
Practice Address - Street 1:1198 CLARK ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-1636
Practice Address - Country:US
Practice Address - Phone:740-432-6012
Practice Address - Fax:740-435-8552
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-050964207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0626719Medicaid
OHA16453Medicare UPIN
OH0626719Medicaid