Healthcare Provider Details

I. General information

NPI: 1740405364
Provider Name (Legal Business Name): MILY J. KANNARKAT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 FAIRFAX AVE SUITE 201
NORFOLK VA
23507-1914
US

IV. Provider business mailing address

PO BOX 936
NORFOLK VA
23501-0936
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-7040
  • Fax: 757-446-7049
Mailing address:
  • Phone: 757-446-7040
  • Fax: 757-446-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number0101249801
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: