Provider Demographics
NPI:1457331100
Name:CONNELLY, ROBERT EDWARD (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 WEST ST
Mailing Address - Street 2:PO BOX 1027
Mailing Address - City:PITTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27312-9533
Mailing Address - Country:US
Mailing Address - Phone:919-542-2020
Mailing Address - Fax:919-545-0922
Practice Address - Street 1:485 WEST ST
Practice Address - Street 2:
Practice Address - City:PITTSBORO
Practice Address - State:NC
Practice Address - Zip Code:27312-9533
Practice Address - Country:US
Practice Address - Phone:919-542-2020
Practice Address - Fax:919-545-0922
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909174Medicaid
NC09174OtherBCBS
NC8909174Medicaid
NCT64906Medicare UPIN