Provider Demographics
NPI:1598793697
Name:CONNOLLY, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-8000
Mailing Address - Country:US
Mailing Address - Phone:972-390-1805
Mailing Address - Fax:972-390-1890
Practice Address - Street 1:515 W MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-8000
Practice Address - Country:US
Practice Address - Phone:972-390-1805
Practice Address - Fax:972-390-1890
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine