Provider Demographics
NPI:1447540356
Name:G. M. CONEKIN, III, OD, PA
Entity type:Organization
Organization Name:G. M. CONEKIN, III, OD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONEKIN
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:910-353-0541
Mailing Address - Street 1:200 DOCTORS DRIVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6308
Mailing Address - Country:US
Mailing Address - Phone:910-353-0541
Mailing Address - Fax:910-353-5353
Practice Address - Street 1:200 DOCTORS DR
Practice Address - Street 2:SUITE K
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6310
Practice Address - Country:US
Practice Address - Phone:910-353-0541
Practice Address - Fax:910-353-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1181152W00000X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X
NC2082152W00000X, 152WC0802X, 152WP0200X
NC2122152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09328OtherBCBS
NC170000072OtherRAILROAD MEDICARE
NCY1605OtherBLIND COMMISSION
NC7909328Medicaid
NC170000072OtherRAILROAD MEDICARE
NC7909328Medicaid
NC09328OtherBCBS
NC0131800001Medicare NSC