Provider Demographics
NPI:1336540939
Name:RAVEENDRANATHAN, PRANEETHA (OD)
Entity Type:Individual
Prefix:
First Name:PRANEETHA
Middle Name:
Last Name:RAVEENDRANATHAN
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 1:501 E KOLSTAD ST
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-2352
Mailing Address - Country:US
Mailing Address - Phone:903-731-4653
Mailing Address - Fax:903-723-5550
Practice Address - Street 1:105 W 7TH AVE STE 800
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-6430
Practice Address - Country:US
Practice Address - Phone:903-874-0005
Practice Address - Fax:903-874-0009
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2024-05-17
Deactivation Date:2024-04-30
Deactivation Code:
Reactivation Date:2024-05-17
Provider Licenses
StateLicense IDTaxonomies
TX8469T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist