Provider Demographics
NPI:1417943713
Name:CONNELLY, KEVIN GERARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GERARD
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1201 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4215
Mailing Address - Country:US
Mailing Address - Phone:817-335-5288
Mailing Address - Fax:817-338-0927
Practice Address - Street 1:1201 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4215
Practice Address - Country:US
Practice Address - Phone:817-335-5288
Practice Address - Fax:817-338-0927
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7600207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036910001Medicaid
TX80191KMedicare PIN
TX036910001Medicaid