Provider Demographics
NPI: | 1639333107 |
---|---|
Name: | CONNOR, JUSTIN R (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JUSTIN |
Middle Name: | R |
Last Name: | CONNOR |
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: | 1057 S BRADFORD ST |
Mailing Address - Street 2: | |
Mailing Address - City: | DOVER |
Mailing Address - State: | DE |
Mailing Address - Zip Code: | 19904-4141 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 302-231-1245 |
Mailing Address - Fax: | 302-231-1246 |
Practice Address - Street 1: | 1057 S BRADFORD ST |
Practice Address - Street 2: | |
Practice Address - City: | DOVER |
Practice Address - State: | DE |
Practice Address - Zip Code: | 19904-4141 |
Practice Address - Country: | US |
Practice Address - Phone: | 302-231-1245 |
Practice Address - Fax: | 302-231-1246 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-07-15 |
Last Update Date: | 2022-02-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
DC | 530196961 | 207X00000X |
DE | C7-0004483 | 207XP3100X |
DE | C1-0009837 | 207XP3100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207XP3100X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KS | 201159650A | Medicaid | |
DE | 250499212 | Medicaid |