Provider Demographics
NPI:1962616227
Name:LAURENCE CONNELLEY
Entity type:Organization
Organization Name:LAURENCE CONNELLEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:CONNELLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:501-221-2266
Mailing Address - Street 1:10020 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-2130
Mailing Address - Country:US
Mailing Address - Phone:501-221-2266
Mailing Address - Fax:501-224-5660
Practice Address - Street 1:10020 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-2130
Practice Address - Country:US
Practice Address - Phone:501-221-2266
Practice Address - Fax:501-224-5660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR59213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104333717Medicaid
AR128479748Medicaid
AR480015481OtherRAILROAD MEDICARE
AR0152490001Medicare NSC
AR56070Medicare PIN
AR5B193Medicare PIN
AR104333717Medicaid