Healthcare Provider Details

I. General information

NPI: 1164594628
Provider Name (Legal Business Name): RANDY WAIN CONNOLLY DO, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR STE 1100
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

620 JOHN PAUL JONES CIR STE 1100
PORTSMOUTH VA
23708-2111
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-0765
  • Fax:
Mailing address:
  • Phone: 757-953-0765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0102201963
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number0102201963
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: