Provider Demographics
NPI:1255816674
Name:KANUKUNTLA, VASANTHA KUMARI (OD)
Entity type:Individual
Prefix:
First Name:VASANTHA
Middle Name:KUMARI
Last Name:KANUKUNTLA
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 1:321 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1016
Mailing Address - Country:US
Mailing Address - Phone:817-529-9949
Mailing Address - Fax:817-529-9943
Practice Address - Street 1:321 S HENDERSON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-1016
Practice Address - Country:US
Practice Address - Phone:817-529-9949
Practice Address - Fax:817-529-9943
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9522T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist