Provider Demographics
NPI:1114972783
Name:CONNELLY, MARY OLSEN (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:OLSEN
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 E SENECA ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-3747
Mailing Address - Country:US
Mailing Address - Phone:520-318-0027
Mailing Address - Fax:
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-795-8188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ68491207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ937295Medicaid