Healthcare Provider Details

I. General information

NPI: 1205852696
Provider Name (Legal Business Name): YAZHOLI KANIKKANNAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 COLUMBIA ST
POUGHKEEPSIE NY
12601-3906
US

IV. Provider business mailing address

110 S BEDFORD RD CAREMOUNT MEDICAL PC
MOUNT KISCO NY
10549-3446
US

V. Phone/Fax

Practice location:
  • Phone: 845-231-5600
  • Fax: 845-592-7708
Mailing address:
  • Phone: 914-241-1050
  • Fax: 914-242-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number247180
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: