Provider Demographics
NPI:1033267406
Name:AGARWAL, VIJAY KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:KUMAR
Last Name:AGARWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 N 120TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-4212
Mailing Address - Country:US
Mailing Address - Phone:402-493-2100
Mailing Address - Fax:402-493-2104
Practice Address - Street 1:727 N 120TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4212
Practice Address - Country:US
Practice Address - Phone:402-493-2100
Practice Address - Fax:402-493-2104
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16006208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47083662100Medicaid
NE35053OtherBLUE CROSS PROVIDER #
NE35053OtherBLUE CROSS PROVIDER #
NE274055AGMedicare ID - Type Unspecified