Provider Demographics
NPI:1780648725
Name:CONNOLLY, BONNIE (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
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:DEPT LA 21069
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1069
Mailing Address - Country:US
Mailing Address - Phone:714-628-3211
Mailing Address - Fax:714-639-0593
Practice Address - Street 1:DEPT LA 21069
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91185-1069
Practice Address - Country:US
Practice Address - Phone:714-628-3211
Practice Address - Fax:714-639-0593
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBC082902174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4597443Medicaid
MI4597443Medicaid
MIH62545Medicare UPIN