Provider Demographics
NPI:1184061905
Name:CONNOLLY, ROBERT EDWARD (LAC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 EXECUTIVE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4164
Mailing Address - Country:US
Mailing Address - Phone:845-649-3305
Mailing Address - Fax:
Practice Address - Street 1:2 EXECUTIVE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4164
Practice Address - Country:US
Practice Address - Phone:845-649-3305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000621-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist