Provider Demographics
NPI:1003996596
Name:CONNOLLY, PATRICK DAVID (DC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:DAVID
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 BOND ST
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712
Mailing Address - Country:US
Mailing Address - Phone:732-775-0622
Mailing Address - Fax:
Practice Address - Street 1:418 BOND ST
Practice Address - Street 2:
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712
Practice Address - Country:US
Practice Address - Phone:732-775-0622
Practice Address - Fax:732-775-0662
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00618800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ086097Medicare ID - Type Unspecified