Provider Demographics
NPI:1508884016
Name:CONNELLY, JAMES BRIAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BRIAN
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:3243 EVERGREEN RD N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1214
Mailing Address - Country:US
Mailing Address - Phone:701-298-9421
Mailing Address - Fax:701-298-9421
Practice Address - Street 1:517 DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4414
Practice Address - Country:US
Practice Address - Phone:701-642-9302
Practice Address - Fax:701-642-4321
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND481152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDU09758Medicare UPIN