Healthcare Provider Details

I. General information

NPI: 1255390555
Provider Name (Legal Business Name): MICHAEL CONNOLLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 MAIN ST SUITE 3C
STRATFORD CT
06614-4946
US

IV. Provider business mailing address

2900 MAIN ST SUITE 3C
STRATFORD CT
06614-4946
US

V. Phone/Fax

Practice location:
  • Phone: 203-378-3080
  • Fax: 203-377-3897
Mailing address:
  • Phone: 203-378-3080
  • Fax: 203-377-3897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number028136
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number028136
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: