Provider Demographics
NPI:1093860082
Name:CONNELL, KERRY TIMOTHY (OD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:TIMOTHY
Last Name:CONNELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1514
Mailing Address - Country:US
Mailing Address - Phone:207-284-4560
Mailing Address - Fax:207-283-0309
Practice Address - Street 1:323 MAIN ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1514
Practice Address - Country:US
Practice Address - Phone:207-284-4560
Practice Address - Fax:207-283-0309
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME109280499Medicaid
ME8586932OtherCIGNA
MEMNT1036OtherHARVARD PILGRIM
ME001138OtherANTHEM
ME702123Medicare PIN
ME001138OtherANTHEM
ME580002561Medicare PIN