Basic Information
Provider Information | |||||||||
NPI: | 1780802389 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONOLEY | ||||||||
FirstName: | JACK | ||||||||
MiddleName: | AUTREY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1195 GARNER FIELD RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | UVALDE | ||||||||
State: | TX | ||||||||
PostalCode: | 788014820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8302783086 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1195 GARNER FIELD RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | UVALDE | ||||||||
State: | TX | ||||||||
PostalCode: | 788014820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8302783086 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2007 | ||||||||
LastUpdateDate: | 11/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N5635 | TX | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0005X | N5635 | TX | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | N5635 | 01 | TX | STATE LICENSE | OTHER |