Provider Demographics
NPI:1528604394
Name:KAKKERA, RAGHAVENDRA
Entity Type:Individual
Prefix:
First Name:RAGHAVENDRA
Middle Name:
Last Name:KAKKERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-2121
Mailing Address - Country:US
Mailing Address - Phone:512-650-7156
Mailing Address - Fax:
Practice Address - Street 1:24 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-2121
Practice Address - Country:US
Practice Address - Phone:512-650-7156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29147225100000X
NY044289225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist