Provider Demographics
NPI:1750509634
Name:KIDS CHOICE PEDIATRICS,LLC
Entity Type:Organization
Organization Name:KIDS CHOICE PEDIATRICS,LLC
Other - Org Name:VENKATESWARA RAO DIKKALA, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKATESWARA
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:DIKKALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-380-9199
Mailing Address - Street 1:2775 CRUSE RD
Mailing Address - Street 2:SUITE 1801
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7140
Mailing Address - Country:US
Mailing Address - Phone:678-380-9199
Mailing Address - Fax:770-935-0199
Practice Address - Street 1:2775 CRUSE RD
Practice Address - Street 2:SUITE 1801
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7140
Practice Address - Country:US
Practice Address - Phone:678-380-9199
Practice Address - Fax:770-935-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048226261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1023076387OtherINDIVIDUAL NPI NUMBER