Provider Demographics
NPI:1396722708
Name:KIKKERI, VINAY N (MD)
Entity type:Individual
Prefix:
First Name:VINAY
Middle Name:N
Last Name:KIKKERI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KIKKERI
Other - Middle Name:N
Other - Last Name:VINAYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:360 BARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1666
Mailing Address - Country:US
Mailing Address - Phone:718-876-2000
Mailing Address - Fax:718-876-2012
Practice Address - Street 1:360 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1666
Practice Address - Country:US
Practice Address - Phone:718-876-2000
Practice Address - Fax:718-876-2012
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2507342085R0202X, 2085R0204X
NY0018742085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02458166Medicaid
NY890281Medicare PIN
NY02458166Medicaid