Healthcare Provider Details

I. General information

NPI: 1689757502
Provider Name (Legal Business Name): JERRY W CONNERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 N GRAND AVE SUITE 200
FORT THOMAS KY
41075-4107
US

IV. Provider business mailing address

40 NORTH GRAND AVE SUITE 200
FT. THOMAS KY
41075
US

V. Phone/Fax

Practice location:
  • Phone: 859-781-2700
  • Fax: 859-781-2712
Mailing address:
  • Phone: 859-781-2700
  • Fax: 859-781-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number15481
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: