Provider Demographics
NPI:1104985035
Name:GEOFFROY, CONWAY PAUL (PT)
Entity type:Individual
Prefix:MR
First Name:CONWAY
Middle Name:PAUL
Last Name:GEOFFROY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:ST. MARTINVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70582
Mailing Address - Country:US
Mailing Address - Phone:337-394-3757
Mailing Address - Fax:337-394-3758
Practice Address - Street 1:400 SOUTH MAIN STREET
Practice Address - Street 2:SUITE D
Practice Address - City:ST. MARTINVILLE
Practice Address - State:LA
Practice Address - Zip Code:70582
Practice Address - Country:US
Practice Address - Phone:337-394-3757
Practice Address - Fax:337-394-3758
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT00233174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1567931Medicaid
LA5X679Medicare ID - Type Unspecified