Provider Demographics
NPI:1497923528
Name:ROBERT J. CONNELLY
Entity Type:Organization
Organization Name:ROBERT J. CONNELLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:607-652-7207
Mailing Address - Street 1:22 HARPER ST
Mailing Address - Street 2:PO BOX 88
Mailing Address - City:STAMFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12167-0088
Mailing Address - Country:US
Mailing Address - Phone:607-652-7207
Mailing Address - Fax:607-652-4753
Practice Address - Street 1:22 HARPER ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:NY
Practice Address - Zip Code:12167-0088
Practice Address - Country:US
Practice Address - Phone:607-652-7207
Practice Address - Fax:607-652-4753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004654332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0130010001Medicare NSC