MEDICARE: DR. KERRY TIMOTHY CONNELL O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT641	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8586932	OTHER	ME	CIGNA
3	MNT1036	OTHER	ME	HARVARD PILGRIM
4	001138	OTHER	ME	ANTHEM

General Provider Information

NPI Number	:	1093860082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KERRY TIMOTHY CONNELL O.D.

Provider Business Mailing Address
First Line	:	323 MAIN ST
Second Line	:
City	:	SACO
State	:	ME
Zip	:	04072-1514
Country	:	US
Telephone Number	:	207-284-4560
Fax Number	:	207-283-0309

Provider Business Practice Location Address
First Line	:	323 MAIN ST
Second Line	:
City	:	SACO
State	:	ME
Zip	:	04072-1514
Country	:	US
Telephone Number	:	207-284-4560
Fax Number	:	207-283-0309

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	05/13/2008

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