Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 244122 | KY |
Y | 222Z00000X | Podiatrist | 244122 | KY |
N | 213EP1101X | Primary Podiatric Medicine | 00180 | KY |
N | 213EP1101X | Primary Podiatric Medicine | 244122 | KY |
N | 213ES0103X | Foot & Ankle Surgery | 00180 | KY |
N | 213ES0103X | Foot & Ankle Surgery | 244122 | KY |
NPI | 1023010279 |
---|---|
Provider Name | Dr. Matthew James Connolly |
First Address | Edgewood, KY 41017-3405 |
Second Address | Edgewood, KY 41017-3405 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2005 |
Last Update Date | 07/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T78551 | (02) |