Provider Demographics
NPI:1275505612
Name:AGARWALA, SANJIV S (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJIV
Middle Name:S
Last Name:AGARWALA
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 1:801 OSTRUM STREET
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:484-526-2140
Mailing Address - Fax:484-526-6055
Practice Address - Street 1:801 OSTRUM STREET
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1000
Practice Address - Country:US
Practice Address - Phone:484-526-2140
Practice Address - Fax:484-526-6055
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052173L174400000X
PAMD051748L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001467202Medicaid
PAF82534Medicare UPIN
PA514379H0SMedicare ID - Type Unspecified
PA514379Medicare PIN