Provider Demographics
NPI:1932105095
Name:CONNOLLY, CHARLES WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1919
Mailing Address - Country:US
Mailing Address - Phone:781-593-1700
Mailing Address - Fax:
Practice Address - Street 1:120 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1919
Practice Address - Country:US
Practice Address - Phone:617-776-2500
Practice Address - Fax:617-776-3850
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1784213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY70860OtherBLUE SHIELD OF MA
MA709158OtherTUFTS HEALTH PLAN
MA0361968Medicaid
MA33386OtherHARVARD PILGRIM HEALTH CA
MA2700037OtherUNITED HEALTHCARE
MA0361968Medicaid
MA709158OtherTUFTS HEALTH PLAN
MA2700037OtherUNITED HEALTHCARE