Provider Demographics
NPI:1477636033
Name:KANNER, ELLIOTT MAKARY (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:MAKARY
Last Name:KANNER
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 1:1407 UNION AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3641
Mailing Address - Country:US
Mailing Address - Phone:901-866-8622
Mailing Address - Fax:
Practice Address - Street 1:930 MADISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103
Practice Address - Country:US
Practice Address - Phone:901-448-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41528207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003179565AMedicaid
MO1477636033Medicaid
AR162929001Medicaid
AL180617Medicaid
TN3827927Medicaid
MS01570301Medicaid