Provider Demographics
NPI:1275549156
Name:AGRAWAL, VIVEK (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVEK
Middle Name:
Last Name:AGRAWAL
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 1:10511 GOLF COURSE RD NW STE 201
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5917
Mailing Address - Country:US
Mailing Address - Phone:505-727-4430
Mailing Address - Fax:505-727-9590
Practice Address - Street 1:10511 GOLF COURSE RD NW STE 201
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5917
Practice Address - Country:US
Practice Address - Phone:505-727-4430
Practice Address - Fax:505-727-9590
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-0982207X00000X
IN01054190A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90631846Medicaid
IN200325410Medicaid
IN200325410Medicaid
INH04053Medicare UPIN
IN000000509540OtherANTHEM PIN