MEDICARE: DR. SELVIN ROBIN GNANAKKAN O.D. M.B.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0618001366	VA
2	152W00000X	Optometrist	OEG003214	PA
3	152W00000X	Optometrist	TPOP129	FL
4	207W00000X	Ophthalmology Physician	TA1769	MD
5	152W00000X	Optometrist	1976-922AT	LA
6	152W00000X	Optometrist	21201-875	WI
7	152W00000X	Optometrist	OPT-001127	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104980846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SELVIN ROBIN GNANAKKAN O.D. M.B.A

Provider Business Mailing Address
First Line	:	8614 WESTWOOD CENTER DR FL 9
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-2442
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	7122 N 59TH AVE FL 1
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85301-2436
Country	:	US
Telephone Number	:	623-931-1043
Fax Number	:	602-535-3165

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	02/12/2026

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