Provider Demographics
NPI:1669791893
Name:MCCONNELL, MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCCONNELL
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 BULL VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-8084
Mailing Address - Country:US
Mailing Address - Phone:847-533-6498
Mailing Address - Fax:
Practice Address - Street 1:12490 BUSINESS CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5833
Practice Address - Country:US
Practice Address - Phone:760-728-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A207192085R0202X
IL036.1397052085R0202X
TXQ42002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.139705OtherMEDICAL LICENSE