Provider Demographics
NPI:1063497139
Name:AGRAWAL, MANJU L (MD)
Entity Type:Individual
Prefix:
First Name:MANJU
Middle Name:L
Last Name:AGRAWAL
Suffix:
Gender:F
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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:AMBULATORY CARE CLINIC
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-5512
Practice Address - Fax:214-590-5491
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138884502Medicaid
TX138884510Medicaid
TX138884512Medicaid
TX81Y188OtherBLUE CROSS BLUE SHIELD
TX138884505Medicaid
TX138884511Medicaid
TX138884508Medicaid
TX138884509Medicaid
TX138884507Medicaid
TX138884506Medicaid
TX138884501Medicaid
TX138884503Medicaid
TX138884504Medicaid
TX138884509Medicaid
TX138884501Medicaid