Provider Demographics
NPI:1740226026
Name:CONNOLLY, ROBIN JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:JOHN
Last Name:CONNOLLY
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 1:2580 NW EVENTIDE PL
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-9146
Mailing Address - Country:US
Mailing Address - Phone:772-398-2233
Mailing Address - Fax:772-398-2244
Practice Address - Street 1:1825 SE TIFFANY AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7554
Practice Address - Country:US
Practice Address - Phone:772-398-2233
Practice Address - Fax:772-398-2244
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME574282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051223100Medicaid
FL11634OtherBCBS PROVIDER NUMBER
FLD48143Medicare UPIN