Provider Demographics
NPI:1467480780
Name:AGARWAL, MUKESH CHANDRA (MD)
Entity Type:Individual
Prefix:
First Name:MUKESH
Middle Name:CHANDRA
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 1:3614 BLANDING BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-5241
Mailing Address - Country:US
Mailing Address - Phone:904-419-7100
Mailing Address - Fax:904-643-4530
Practice Address - Street 1:3614 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-5241
Practice Address - Country:US
Practice Address - Phone:904-419-7100
Practice Address - Fax:904-643-4530
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132766207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000698288IMedicaid
GA085002995GMedicaid
GAGRP4490Medicare UPIN
GA085002995GMedicaid
GA11BDVQBMedicare PIN