Provider Demographics
NPI:1538246202
Name:CONNELLEY, JON R (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:CONNELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2336
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-2336
Mailing Address - Country:US
Mailing Address - Phone:870-424-7070
Mailing Address - Fax:870-424-6616
Practice Address - Street 1:624 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 503
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2955
Practice Address - Country:US
Practice Address - Phone:870-508-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-8366207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100081120BMedicaid
AR130416001Medicaid
AR126543001Medicaid
OK100081120BMedicaid
AR5K2437741Medicare PIN
AR130416001Medicaid
O50075401Medicare PIN