Provider Demographics
NPI:1740215383
Name:MAES-PUKALA, KATHLEEN ANN (OD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:MAES-PUKALA
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 1:841 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6865
Mailing Address - Country:US
Mailing Address - Phone:615-220-6108
Mailing Address - Fax:
Practice Address - Street 1:841 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6865
Practice Address - Country:US
Practice Address - Phone:615-220-6108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008577152W00000X
TN3116152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist