Healthcare Provider Details

I. General information

NPI: 1962597310
Provider Name (Legal Business Name): BRENDA JEAN CONNOLLY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4038 WEST RD
CORTLAND NY
13045-1842
US

IV. Provider business mailing address

17 MAIN ST SUITE 302
CORTLAND NY
13045-6606
US

V. Phone/Fax

Practice location:
  • Phone: 607-758-3008
  • Fax: 607-758-3019
Mailing address:
  • Phone: 607-753-3797
  • Fax: 607-753-6677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number219374
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: