Provider Demographics
NPI:1659307296
Name:CONNELL, NORMAN L JR (MD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:L
Last Name:CONNELL
Suffix:JR
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 1:2100 HIGHWAY 61 N
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8211
Mailing Address - Country:US
Mailing Address - Phone:601-883-5000
Mailing Address - Fax:
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-883-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16732207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS7023123OtherAETNA
MS0122875Medicaid
LA1483621Medicaid
MS7023123OtherAETNA
LA1483621Medicaid
MS160059688Medicare PIN
MS160000570Medicare PIN