Provider Demographics
NPI:1922001650
Name:CONNOLLY, ADRIAN L III (MD)
Entity Type:Individual
Prefix:DR
First Name:ADRIAN
Middle Name:L
Last Name:CONNOLLY
Suffix:III
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 1:101 OLD SHORT HILLS RD
Mailing Address - Street 2:STE 503
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1023
Mailing Address - Country:US
Mailing Address - Phone:973-731-9131
Mailing Address - Fax:973-731-9201
Practice Address - Street 1:101 OLD SHORT HILLS RD
Practice Address - Street 2:STE 503
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1023
Practice Address - Country:US
Practice Address - Phone:973-731-9131
Practice Address - Fax:973-731-9201
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA036148207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4811801Medicaid
NJMA036148OtherMEDICAL LICENSE
NJ223759844OtherEIN
NJMA036148OtherMEDICAL LICENSE
NJB79594Medicare UPIN