Provider Demographics
NPI:1679641153
Name:RONALD G CONNOLLY MD
Entity Type:Organization
Organization Name:RONALD G CONNOLLY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-974-7000
Mailing Address - Street 1:1776 YGNACIO VALLEY ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598
Mailing Address - Country:US
Mailing Address - Phone:925-974-7000
Mailing Address - Fax:925-974-7003
Practice Address - Street 1:1776 YGNACIO VALLEY ROAD
Practice Address - Street 2:SUITE 106
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598
Practice Address - Country:US
Practice Address - Phone:925-974-7000
Practice Address - Fax:925-974-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13521207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G135210Medicaid
C48621Medicare UPIN
CA00G135211Medicare PIN