Provider Demographics
NPI:1679500417
Name:CONNOLLY, SEAN FITZPATRICK SR (DPM)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:FITZPATRICK
Last Name:CONNOLLY
Suffix:SR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3614
Mailing Address - Country:US
Mailing Address - Phone:617-387-4200
Mailing Address - Fax:617-387-8852
Practice Address - Street 1:459 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3614
Practice Address - Country:US
Practice Address - Phone:617-387-4200
Practice Address - Fax:617-387-8852
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1981213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAU36625Medicare UPIN
MAY70962Medicare ID - Type Unspecified