Provider Demographics
NPI:1316980394
Name:CONNOLLY, SEAN G (OD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:G
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21780 21 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2974
Mailing Address - Country:US
Mailing Address - Phone:586-421-2020
Mailing Address - Fax:586-421-2022
Practice Address - Street 1:21780 21 MILE RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-2974
Practice Address - Country:US
Practice Address - Phone:586-242-7761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003864152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU77978Medicare UPIN