Provider Demographics
NPI:1316927221
Name:PURCELL-CANNON, KATHLEEN (OD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:PURCELL-CANNON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7323 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2902
Mailing Address - Country:US
Mailing Address - Phone:803-750-6600
Mailing Address - Fax:803-750-6601
Practice Address - Street 1:7323 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2902
Practice Address - Country:US
Practice Address - Phone:803-750-6600
Practice Address - Fax:803-750-6601
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC982152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD09823Medicaid
SCD09823Medicaid
SCU33923Medicare UPIN
SCU339231381Medicare PIN