Provider Demographics
NPI:1730436007
Name:JULIE CONYERS MD INC
Entity type:Organization
Organization Name:JULIE CONYERS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-926-5211
Mailing Address - Street 1:635 LASSEN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9003
Mailing Address - Country:US
Mailing Address - Phone:530-926-5211
Mailing Address - Fax:530-926-5740
Practice Address - Street 1:635 LASSEN LN
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-9003
Practice Address - Country:US
Practice Address - Phone:530-926-5211
Practice Address - Fax:530-926-5740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG89174208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty