Healthcare Provider Details

I. General information

NPI: 1841268174
Provider Name (Legal Business Name): ROBERT GERARD CONNOLLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL CAMP PENDLETON BLDG H100 CODE 094
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

10661 HUNTERS GLEN DR
SAN DIEGO CA
92130-4851
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1330
  • Fax:
Mailing address:
  • Phone: 858-793-1259
  • Fax: 858-793-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberG69229
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: