Healthcare Provider Details

I. General information

NPI: 1295468973
Provider Name (Legal Business Name): SRIJAA KANNAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 08/26/2022
Certification Date: 07/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 LUCERNE TERRANCE MP818 2ND FLOOR
ORLANDO FL
32806
US

IV. Provider business mailing address

1401 LUCERNE TERRANCE MP818 2ND FLOOR
ORLANDO FL
32806
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-5297
  • Fax:
Mailing address:
  • Phone: 321-841-5297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number8750
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: