Provider Demographics
NPI:1003341157
Name:CONNOLLY, MATTHEW TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TIMOTHY
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:W6247 SAINT ANDREWS CT
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-2710
Mailing Address - Country:US
Mailing Address - Phone:414-526-6371
Mailing Address - Fax:
Practice Address - Street 1:3100 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1948
Practice Address - Country:US
Practice Address - Phone:920-783-1261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70428-20207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology