Provider Demographics
NPI:1336540939
Name:RAVEENDRANATHAN, PRANEETHA (OD)
Entity type:Individual
Prefix:
First Name:PRANEETHA
Middle Name:
Last Name:RAVEENDRANATHAN
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 1:1095 MORRIS AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083
Mailing Address - Country:US
Mailing Address - Phone:973-622-2020
Mailing Address - Fax:908-686-2525
Practice Address - Street 1:1095 MORRIS AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083
Practice Address - Country:US
Practice Address - Phone:973-622-2020
Practice Address - Fax:908-686-2525
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2024-05-21
Deactivation Date:2024-04-30
Deactivation Code:
Reactivation Date:2024-05-17
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00712100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist