1750509634 NPI number — KIDS CHOICE PEDIATRICS,LLC

Table of content: (NPI 1750509634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750509634 NPI number — KIDS CHOICE PEDIATRICS,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDS CHOICE PEDIATRICS,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VENKATESWARA RAO DIKKALA, M.D.
Provider Other Organization Name Type Code:
3
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:
1750509634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2775 CRUSE RD
Provider Second Line Business Mailing Address:
SUITE 1801
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30044-7140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-380-9199
Provider Business Mailing Address Fax Number:
770-935-0199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2775 CRUSE RD
Provider Second Line Business Practice Location Address:
SUITE 1801
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30044-7140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-380-9199
Provider Business Practice Location Address Fax Number:
770-935-0199
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DIKKALA
Authorized Official First Name:
VENKATESWARA
Authorized Official Middle Name:
RAO
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
678-380-9199

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  048226 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1023076387 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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