1396745311 NPI number — DR. NAGARAJ S KIKKERI M.D.

Table of content: DR. NAGARAJ S KIKKERI M.D. (NPI 1396745311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396745311 NPI number — DR. NAGARAJ S KIKKERI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIKKERI
Provider First Name:
NAGARAJ
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396745311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/22/2006
NPI Reactivation Date:
04/04/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3865 CHILDRESS AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MESQUITE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75150-2802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-681-7246
Provider Business Mailing Address Fax Number:
972-681-8946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3865 CHILDRESS AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75150-2802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-681-7246
Provider Business Practice Location Address Fax Number:
972-681-8946
Provider Enumeration Date:
08/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  K9584 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: K9584 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 610792000 . This is a "DEPT. OF LABOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8R5340 . This is a "BCBS KIKKERI INTERANTIONA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 097018807 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8M0103 . This is a "BCBS MPA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8K5591 . This is a "BCBS MAA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8M0110 . This is a "BCBS WRA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 097018808 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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