Basic Information
| Provider Information | |||||||||
| NPI: | 1598761330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONWAY | ||||||||
| FirstName: | MANDI | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONWAY | ||||||||
| OtherFirstName: | MARIANNE | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19052 N R H JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853754401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234743937 | ||||||||
| FaxNumber: | 6239757005 | ||||||||
| Practice Location | |||||||||
| Address1: | 19052 RH JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853524401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234743937 | ||||||||
| FaxNumber: | 6239757005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 31569 | AZ | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 06499 | LA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 31569 | AZ | Y |
ID Information
| ID | Type | State | Issuer | Description | 1363995 | 05 | LA | MEDICAID | 00122904 | 01 | MS | MISSISSIPPI MEDICAID | OTHER | 111585 | 05 | AZ | MEDICAID | P00430021 | 01 | AZ | RAILROAD MEDICARE | OTHER |