Provider Demographics
NPI:1407411689
Name:AGARWAL, POOJA
Entity Type:Individual
Prefix:
First Name:POOJA
Middle Name:
Last Name:AGARWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2554 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2930
Mailing Address - Country:US
Mailing Address - Phone:773-682-4903
Mailing Address - Fax:
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-5372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250762592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty