Healthcare Provider Details

I. General information

NPI: 1104937218
Provider Name (Legal Business Name): KIKKERI INTERNATIONAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3865 CHILDRESS AVE STE A
MESQUITE TX
75150
US

IV. Provider business mailing address

PO BOX 870638
MESQUITE TX
75187-0638
US

V. Phone/Fax

Practice location:
  • Phone: 972-681-7246
  • Fax: 972-681-1079
Mailing address:
  • Phone: 972-681-7246
  • Fax: 972-681-8946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM4398
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberK4140
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberK9584
License Number StateTX

VIII. Authorized Official

Name: DR. NAGARAJ KIKKERI
Title or Position: OWNER
Credential: MD
Phone: 972-681-7246