Provider Demographics
NPI:1467465674
Name:CONNOLLY, EDWARD F (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:F
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2101 VALE RD
Mailing Address - Street 2:#301
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3835
Mailing Address - Country:US
Mailing Address - Phone:510-236-4500
Mailing Address - Fax:510-236-0291
Practice Address - Street 1:2101 VALE RD
Practice Address - Street 2:#301
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3835
Practice Address - Country:US
Practice Address - Phone:510-236-4500
Practice Address - Fax:510-236-0291
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2012-07-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG23552208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G235520Medicaid
CA00G235520Medicaid