Provider Demographics
NPI:1457373391
Name:CONNOLLY, KEVIN F (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:F
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 1:404-B BLACK HILLS LN SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8148
Mailing Address - Country:US
Mailing Address - Phone:360-438-2727
Mailing Address - Fax:360-923-1120
Practice Address - Street 1:404-B BLACK HILLS LN SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8148
Practice Address - Country:US
Practice Address - Phone:360-438-2727
Practice Address - Fax:360-923-1120
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000141052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA18095OtherLABOR & INDUSTRY
WA1849207Medicaid
WA1849207Medicaid
WA001000219Medicare ID - Type UnspecifiedMEDICARE PERFORMING NUMBE