Provider Demographics
NPI:1518941665
Name:CONNOLLY, MICHAEL J (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2202 N FORBES BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1412
Mailing Address - Country:US
Mailing Address - Phone:520-760-8972
Mailing Address - Fax:520-760-3417
Practice Address - Street 1:8826 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85749-9607
Practice Address - Country:US
Practice Address - Phone:520-760-8972
Practice Address - Fax:520-760-3417
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3660207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ577372Medicaid
AZ577372Medicaid
H25172Medicare UPIN