Basic Information
| Provider Information | |||||||||
| NPI: | 1316980394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONNOLLY | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21780 21 MILE RD | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480442974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864212020 | ||||||||
| FaxNumber: | 5864212022 | ||||||||
| Practice Location | |||||||||
| Address1: | 21780 21 MILE RD | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480442974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862427761 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901003864 | MI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.