Basic Information
Provider Information | |||||||||
NPI: | 1801927199 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCONNELL | ||||||||
FirstName: | JULIE | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOHNSON | ||||||||
OtherFirstName: | JULIE | ||||||||
OtherMiddleName: | W | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 185 ROUTE 36 | ||||||||
Address2: | STE 130 | ||||||||
City: | WEST LONG BRANCH | ||||||||
State: | NJ | ||||||||
PostalCode: | 077641339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2019678221 | ||||||||
FaxNumber: | 2016349647 | ||||||||
Practice Location | |||||||||
Address1: | 466 OLD HOOK ROAD | ||||||||
Address2: | SUITE 1 | ||||||||
City: | EMERSON | ||||||||
State: | NJ | ||||||||
PostalCode: | 07630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2019678221 | ||||||||
FaxNumber: | 2016349647 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2007 | ||||||||
LastUpdateDate: | 01/08/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 57316 | GA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | ME87478 | FL | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 25MA08278700 | NJ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.