=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558402768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID CONYACK D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S ORANGE AVE SUITE 201
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039-5817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 197-332-7799
-----------------------------------------------------
Fax | 973-322-7791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 551420
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33355-1420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-243-3839
-----------------------------------------------------
Fax | 844-414-8291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | MB06042200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | MB06042200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | MB06042200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | MB06042200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 25MB06042200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------