MEDICARE: BONNIE CONNOLLY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	BC082902	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780648725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE CONNOLLY MD

Provider Business Mailing Address
First Line	:	DEPT LA 21069
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91185-1069
Country	:	US
Telephone Number	:	714-628-3211
Fax Number	:	714-639-0593

Provider Business Practice Location Address
First Line	:	DEPT LA 21069
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91185-1069
Country	:	US
Telephone Number	:	714-628-3211
Fax Number	:	714-639-0593

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	12/13/2011

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