Provider Demographics
NPI:1609877620
Name:CONNELLY, JASON ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ROBERT
Last Name:CONNELLY
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:335 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:NC
Practice Address - Zip Code:27013-9501
Practice Address - Country:US
Practice Address - Phone:704-210-7885
Practice Address - Fax:704-210-7898
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000386207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC126RGOtherBLUE CROSS BLUE SHIELD NC
NC89126RGMedicaid
NC89126RGMedicaid
NC126RGOtherBLUE CROSS BLUE SHIELD NC
NC2280542AMedicare PIN