Provider Demographics
NPI:1952415689
Name:CONNER, JOSHUA S (OD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:S
Last Name:CONNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E DAY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3408
Mailing Address - Country:US
Mailing Address - Phone:574-271-3939
Mailing Address - Fax:574-271-3941
Practice Address - Street 1:230 E DAY RD STE 100
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3408
Practice Address - Country:US
Practice Address - Phone:574-271-3939
Practice Address - Fax:574-271-3941
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001633152W00000X
IN18003496A152W00000X
KY1679DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18003496AOtherLICENSE
INP00653119OtherRR MEDICARE
IN200888800Medicaid
INP00653119OtherRR MEDICARE
IN4823160002Medicare NSC
IN4823160003Medicare NSC
IN18003496AOtherLICENSE
IN4823160004Medicare NSC