Provider Demographics
NPI:1407986631
Name:CONNELLY, TIMOTHY GERARD (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GERARD
Last Name:CONNELLY
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 1:690 CANTON ST
Mailing Address - Street 2:STE 325
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2324
Mailing Address - Country:US
Mailing Address - Phone:401-490-7530
Mailing Address - Fax:401-490-7533
Practice Address - Street 1:825 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4728
Practice Address - Country:US
Practice Address - Phone:401-456-2666
Practice Address - Fax:401-456-2196
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77171207L00000X
RIDO-390207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIE99040Medicare UPIN