Provider Demographics
NPI:1124076120
Name:CONNOLLY, DEIRDRE M (MD)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:M
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 VILLAGE SQ
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-2712
Mailing Address - Country:US
Mailing Address - Phone:978-323-2835
Mailing Address - Fax:978-323-2836
Practice Address - Street 1:23 VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-2712
Practice Address - Country:US
Practice Address - Phone:978-323-2835
Practice Address - Fax:978-323-2836
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA205858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9771298Medicaid
MA9771298Medicaid
MAH05995Medicare UPIN