Provider Demographics
NPI:1790947836
Name:CONNELL, DONALD WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:WAYNE
Last Name:CONNELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6719 MAYNARDVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-5348
Mailing Address - Country:US
Mailing Address - Phone:865-922-3937
Mailing Address - Fax:
Practice Address - Street 1:6719 MAYNARDVILLE PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-5348
Practice Address - Country:US
Practice Address - Phone:865-922-3937
Practice Address - Fax:865-922-8412
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2805152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522487Medicaid
TN1522487Medicaid