Healthcare Provider Details

I. General information

NPI: 1396745311
Provider Name (Legal Business Name): NAGARAJ S KIKKERI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date: 03/22/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

3865 CHILDRESS AVE SUITE A
MESQUITE TX
75150-2802
US

IV. Provider business mailing address

3865 CHILDRESS AVE SUITE A
MESQUITE TX
75150-2802
US

V. Phone/Fax

Practice location:
  • Phone: 972-681-7246
  • Fax: 972-681-8946
Mailing address:
  • Phone: 972-681-7246
  • Fax: 972-681-8946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberK9584
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberK9584
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: