Healthcare Provider Details

I. General information

NPI: 1962186833
Provider Name (Legal Business Name): SRIVIDYA KANNAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8055 SPYGLASS HILL RD STE 102
MELBOURNE FL
32940-8564
US

IV. Provider business mailing address

8055 SPYGLASS HILL RD STE 102
MELBOURNE FL
32940-8564
US

V. Phone/Fax

Practice location:
  • Phone: 321-842-9551
  • Fax: 321-842-5595
Mailing address:
  • Phone: 321-842-9551
  • Fax: 321-842-5595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME177886
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: