Healthcare Provider Details

I. General information

NPI: 1447540356
Provider Name (Legal Business Name): G. M. CONEKIN, III, OD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DOCTORS DR SUITE K
JACKSONVILLE NC
28546-6310
US

IV. Provider business mailing address

200 DOCTORS DRIVE SUITE K
JACKSONVILLE NC
28546-6308
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-0541
  • Fax: 910-353-5353
Mailing address:
  • Phone: 910-353-0541
  • Fax: 910-353-5353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2082
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2122
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2082
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2122
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1181
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1181
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2082
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2122
License Number StateNC
# 9
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number1181
License Number StateNC
# 10
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1181
License Number StateNC
# 11
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1181
License Number StateNC

VIII. Authorized Official

Name: DR. GEORGE M. CONEKIN III
Title or Position: OWNER
Credential: OD
Phone: 910-353-0541