Provider Demographics
NPI:1447669635
Name:CONNELL, MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CONNELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2944 NW MODA WAY
Mailing Address - Street 2:APT. 723
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-7023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1260 LLOYD CTR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1301
Practice Address - Country:US
Practice Address - Phone:503-331-3984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3194152W00000X
OR3638ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist