Provider Demographics
NPI:1053393934
Name:MCCONNELL, ROBERT J (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 235
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-2427
Mailing Address - Country:US
Mailing Address - Phone:937-890-1725
Mailing Address - Fax:937-890-1725
Practice Address - Street 1:107 KENBROOK DR
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-2427
Practice Address - Country:US
Practice Address - Phone:937-890-1725
Practice Address - Fax:937-890-1725
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH34001569207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH010047653OtherRAILROAD MEDICARE
OH000000003522OtherBC/BS
OH0020391Medicaid
OHA14298OtherUPIN
OHA14298OtherUPIN
OH0020391Medicaid
OH000000003522OtherBC/BS