Provider Demographics
NPI:1316013170
Name:KANNAN, MALATHY (OD)
Entity Type:Individual
Prefix:DR
First Name:MALATHY
Middle Name:
Last Name:KANNAN
Suffix:
Gender:F
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:PO BOX 1606
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-1606
Mailing Address - Country:US
Mailing Address - Phone:210-372-9400
Mailing Address - Fax:
Practice Address - Street 1:12550 LESLIE RD
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4740
Practice Address - Country:US
Practice Address - Phone:210-372-9400
Practice Address - Fax:210-372-9403
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5687-THER.152W00000X
TX6811TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU89447Medicare UPIN