Provider Demographics
NPI:1275724452
Name:KANNAN, VIDHYALAKSHMI (MD)
Entity Type:Individual
Prefix:DR
First Name:VIDHYALAKSHMI
Middle Name:
Last Name:KANNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10238 E HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3316
Mailing Address - Country:US
Mailing Address - Phone:480-257-2669
Mailing Address - Fax:
Practice Address - Street 1:10238 E HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3316
Practice Address - Country:US
Practice Address - Phone:480-257-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0029419207R00000X
AZ46525207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ46525OtherAZ STATE MEDICAL LICENSE BOARD
4663378067OtherMYUTMB 4663378067