MEDICARE: DR. REBECCA CONNELLY OD

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	0003595	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0003595	OTHER	CO	COLORADO DEPARTMENT OF REGULATORY AGENCIES

General Provider Information

NPI Number	:	1467079137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REBECCA CONNELLY OD

Provider Business Mailing Address
First Line	:	2908 DES MOINES DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-6686
Country	:	US
Telephone Number	:	815-931-0011
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 S SHIELDS ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-2583
Country	:	US
Telephone Number	:	970-490-2020
Fax Number	:

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

Provider Enumeration Date	:	06/29/2020
Last Update Date	:	01/29/2021

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