Healthcare Provider Details

I. General information

NPI: 1578797601
Provider Name (Legal Business Name): RAYMOND F. CONWAY III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 SOTOYOME ST
SANTA ROSA CA
95405-4823
US

IV. Provider business mailing address

PO BOX 5651
ORANGE CA
92863-5651
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-4062
  • Fax: 707-525-4095
Mailing address:
  • Phone: 714-571-5000
  • Fax: 714-571-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA112626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: