1801010053 NPI number — ABHISHEK AGARWAL MD

Table of content: ABHISHEK AGARWAL MD (NPI 1801010053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801010053 NPI number — ABHISHEK AGARWAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGARWAL
Provider First Name:
ABHISHEK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801010053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1703 S MERIDIAN STE 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98371-7590
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1703 S MERIDIAN
Provider Second Line Business Practice Location Address:
STE 305
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-841-3933
Provider Business Practice Location Address Fax Number:
253-848-7970
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  MD60647401 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: E5097 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G001045700 . This is a "GROUP PTAN(P)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MD60647401 . This is a "WA LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2060137 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G000188100 . This is a "GROUP PTAN(K)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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