Healthcare Provider Details

I. General information

NPI: 1063863793
Provider Name (Legal Business Name): KAUSHAL KANNAMMAL O. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13750 JAMAICA AVE
JAMAICA NY
11435-3610
US

IV. Provider business mailing address

13750 JAMAICA AVE
JAMAICA NY
11435-3610
US

V. Phone/Fax

Practice location:
  • Phone: 718-298-5100
  • Fax:
Mailing address:
  • Phone: 718-298-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number008447
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: