Provider Demographics
NPI:1174633374
Name:CONNELLY, MAUREEN T (DPM)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:T
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SE 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432
Mailing Address - Country:US
Mailing Address - Phone:561-391-3636
Mailing Address - Fax:561-395-3041
Practice Address - Street 1:22 SE 6TH STREET
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432
Practice Address - Country:US
Practice Address - Phone:561-391-3636
Practice Address - Fax:561-395-3041
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP02508213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
65444CMedicare ID - Type Unspecified
U62139Medicare UPIN
K2436Medicare ID - Type UnspecifiedGROUP #
FL3899920001Medicare NSC