Provider Demographics
NPI:1093754269
Name:CONNOLLY, DOMINIC (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 50421
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:800-793-3529
Mailing Address - Fax:
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-899-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040730207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00287612OtherRAILROAD MEDICARE
H58804OtherGROUP HEALTH
204018OtherWA L & I
WA8323958Medicaid
0730COOtherREGENCE BS
8940418OtherWA CRIME VICTIM
204018OtherWA L & I
H58804OtherGROUP HEALTH
8940418OtherWA CRIME VICTIM
WA8323958Medicaid