Provider Demographics
NPI:1881604700
Name:CONNOLLY, DEIRDRE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:DEIRDRE
Middle Name:MARIE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 E 37TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3001
Mailing Address - Country:US
Mailing Address - Phone:212-779-9485
Mailing Address - Fax:646-837-0808
Practice Address - Street 1:50 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3075
Practice Address - Country:US
Practice Address - Phone:212-679-4134
Practice Address - Fax:212-679-7079
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190888207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG17656Medicare UPIN
03U031Medicare PIN