Provider Demographics
NPI:1972589448
Name:CONNOLLY, JAMES L (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:L
Last Name:CONNOLLY
Suffix:
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 1:1420 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3104
Mailing Address - Country:US
Mailing Address - Phone:985-327-5905
Mailing Address - Fax:205-623-1080
Practice Address - Street 1:1420 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3104
Practice Address - Country:US
Practice Address - Phone:985-327-5905
Practice Address - Fax:205-623-1080
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92995207Y00000X
LAMD205818207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA256408YKENOtherMEDICARE PTAN
FL2728320000Medicaid
FL2728320000Medicaid
FL03520ZMedicare ID - Type Unspecified