Provider Demographics
NPI:1669575809
Name:CONWAY, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:CONWAY
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 1:53 MARION ROAD
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571
Mailing Address - Country:US
Mailing Address - Phone:508-295-8622
Mailing Address - Fax:508-295-4909
Practice Address - Street 1:53 MARION RD
Practice Address - Street 2:SUITE ONE
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571
Practice Address - Country:US
Practice Address - Phone:508-295-8622
Practice Address - Fax:508-295-4909
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39782208000000X
VT0420004648208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2043696Medicaid
J24031Medicare ID - Type Unspecified
MA2043696Medicaid