Provider Demographics
NPI:1245964949
Name:KATSADOUROS, KAYLA KENNETTE TUCKER (OD)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:KENNETTE TUCKER
Last Name:KATSADOUROS
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:KENNETTE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3841 GREEN HILLS VILLAGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 THE VANDERBILT CLINIC
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-3541
Practice Address - Country:US
Practice Address - Phone:615-322-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT007092152W00000X
TN3935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0497034Medicaid