Provider Demographics
NPI:1982617072
Name:CONNELLY, TERENCE P (MD)
Entity Type:Individual
Prefix:
First Name:TERENCE
Middle Name:P
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:3340 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8088
Practice Address - Country:US
Practice Address - Phone:941-764-5858
Practice Address - Fax:941-764-1657
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME63964207RI0011X
FLME0063964174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374413200Medicaid
FL23055XMedicare ID - Type Unspecified