Provider Demographics
NPI:1164096772
Name:CONNOLLY, SHAWN JAMES (DO)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:JAMES
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 SULLIVAN ST
Mailing Address - Street 2:PO BO 1029
Mailing Address - City:WURTSBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12790
Mailing Address - Country:US
Mailing Address - Phone:617-842-0525
Mailing Address - Fax:
Practice Address - Street 1:8811 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5415
Practice Address - Country:US
Practice Address - Phone:210-297-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU8700207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program