Provider Demographics
NPI:1790077576
Name:CONNELLY, MICHAEL WALTER (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WALTER
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-1829
Mailing Address - Country:US
Mailing Address - Phone:201-403-4753
Mailing Address - Fax:
Practice Address - Street 1:60 SADDLE RIVER AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07606-1952
Practice Address - Country:US
Practice Address - Phone:201-880-4860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00691700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor