Provider Demographics
NPI:1649250689
Name:CONNELLEY, JAY ROSS (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:ROSS
Last Name:CONNELLEY
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71657-0417
Mailing Address - Country:US
Mailing Address - Phone:870-460-9001
Mailing Address - Fax:870-412-4575
Practice Address - Street 1:777 JORDAN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5719
Practice Address - Country:US
Practice Address - Phone:870-723-4921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR80133356OtherTRAVERLERS RAILROAD
AR128888001Medicaid
AR77007401OtherBREASTCARE
AR178800000OtherQUALCHOICE
AR80133356OtherTRAVERLERS RAILROAD
ARG19407Medicare UPIN