Healthcare Provider Details

I. General information

NPI: 1497923528
Provider Name (Legal Business Name): ROBERT J. CONNELLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 HARPER ST
STAMFORD NY
12167-0088
US

IV. Provider business mailing address

22 HARPER ST PO BOX 88
STAMFORD NY
12167-0088
US

V. Phone/Fax

Practice location:
  • Phone: 607-652-7207
  • Fax: 607-652-4753
Mailing address:
  • Phone: 607-652-7207
  • Fax: 607-652-4753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number004654
License Number StateNY

VIII. Authorized Official

Name: DR. ROBERT J. CONNELLY
Title or Position: OWNER
Credential: O.D.
Phone: 607-652-7207