Healthcare Provider Details

I. General information

NPI: 1063537249
Provider Name (Legal Business Name): JOHN ELLIS CONLEY II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2152 GOLD DUST CT
TRINITY FL
34655-5015
US

IV. Provider business mailing address

2152 GOLD DUST CT
TRINITY FL
34655-5015
US

V. Phone/Fax

Practice location:
  • Phone: 727-375-8619
  • Fax:
Mailing address:
  • Phone: 727-375-8619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number23641
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number55683
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD6535
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101241572
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: