Provider Demographics
NPI:1346538931
Name:CONNOLLY, BRIAN DANIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DANIEL
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 1:1 STADIUM DRIVE
Mailing Address - Street 2:PO BOX 9235
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505
Mailing Address - Country:US
Mailing Address - Phone:304-293-3091
Mailing Address - Fax:
Practice Address - Street 1:1 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-293-3091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-16
Last Update Date:2015-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26452085R0202X
PAOS0178172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology