Provider Demographics
NPI:1760715833
Name:CONNELLY, WESTON (DO)
Entity Type:Individual
Prefix:
First Name:WESTON
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10549
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-0549
Mailing Address - Country:US
Mailing Address - Phone:727-544-2284
Mailing Address - Fax:727-541-7984
Practice Address - Street 1:6237 66TH ST N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-5025
Practice Address - Country:US
Practice Address - Phone:727-544-2284
Practice Address - Fax:727-541-7984
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11065207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002755800Medicaid
FL14F90OtherBLUE CROSS BLUE SHIELD
FL002755800Medicaid