Provider Demographics
NPI:1104980846
Name:GNANAKKAN, SELVIN ROBIN (OD MBA)
Entity type:Individual
Prefix:DR
First Name:SELVIN
Middle Name:ROBIN
Last Name:GNANAKKAN
Suffix:
Gender:M
Credentials:OD MBA
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4000 OLD COURT RD STE 204
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6415
Mailing Address - Country:US
Mailing Address - Phone:410-653-2400
Mailing Address - Fax:410-653-2402
Practice Address - Street 1:7122 N 59TH AVE FL 1
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2436
Practice Address - Country:US
Practice Address - Phone:623-931-1043
Practice Address - Fax:602-535-3165
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21201-875152W00000X
MDTA1769207W00000X
AZ1127152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ900139064Medicaid
AZU89697Medicare UPIN
Z69691Medicare ID - Type Unspecified