Provider Demographics
NPI:1265064554
Name:CONAUGHTY, MARTIN J (HIS)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:J
Last Name:CONAUGHTY
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 W HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1618
Mailing Address - Country:US
Mailing Address - Phone:618-624-4471
Mailing Address - Fax:618-624-4496
Practice Address - Street 1:1415 W HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1618
Practice Address - Country:US
Practice Address - Phone:618-624-4471
Practice Address - Fax:618-624-4496
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3301237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3301OtherHEARING AID DISPENSER LICENSE