Provider Demographics
NPI:1093708125
Name:CONNOLLY, THOMAS J (MD05/25)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:MD05/25
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2121 PARK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3811
Mailing Address - Country:US
Mailing Address - Phone:904-387-6200
Mailing Address - Fax:904-387-0261
Practice Address - Street 1:2121 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3811
Practice Address - Country:US
Practice Address - Phone:904-387-6200
Practice Address - Fax:904-387-0261
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 855922080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine