Provider Demographics
NPI:1174529309
Name:CONNOLLY, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:650-652-7015
Mailing Address - Fax:650-697-7361
Practice Address - Street 1:1750 EL CAMINO REAL
Practice Address - Street 2:SUITE #307
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010
Practice Address - Country:US
Practice Address - Phone:650-259-1480
Practice Address - Fax:650-697-7361
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56059174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ83789ZMedicaid
ZZZ83789ZMedicare ID - Type Unspecified
CAZZZ83789ZMedicaid