Provider Demographics
NPI:1740282003
Name:CONNELL, DON R (MD)
Entity type:Individual
Prefix:
First Name:DON
Middle Name:R
Last Name:CONNELL
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 1:112 LAKE TOMACHEECHEE DR
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-5117
Mailing Address - Country:US
Mailing Address - Phone:912-826-7310
Mailing Address - Fax:912-826-7310
Practice Address - Street 1:112 LAKE TOMACHEECHEE DR
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5117
Practice Address - Country:US
Practice Address - Phone:912-826-7310
Practice Address - Fax:912-826-7310
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2013-09-18
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
GA0206802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00232889HMedicaid
GAGRP 2523OtherMEDICARE PROVIDER NUMBER
GAE81362Medicare UPIN