Provider Demographics
NPI:1760524649
Name:KOCHANNY, ELIZABETH ANN (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:KOCHANNY
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 1:930 HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5529
Mailing Address - Country:US
Mailing Address - Phone:314-821-6024
Mailing Address - Fax:
Practice Address - Street 1:3 MIDRIVERS MALL DRIVE
Practice Address - Street 2:SEARS OPTICAL
Practice Address - City:ST. PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376
Practice Address - Country:US
Practice Address - Phone:636-970-4554
Practice Address - Fax:636-970-3434
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02607152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist