Provider Demographics
NPI:1528196045
Name:AGRAWAL, VIBHA (MD)
Entity Type:Individual
Prefix:
First Name:VIBHA
Middle Name:
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 1:1017 S FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2621
Mailing Address - Country:US
Mailing Address - Phone:626-403-6200
Mailing Address - Fax:626-403-2580
Practice Address - Street 1:1017 S FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2621
Practice Address - Country:US
Practice Address - Phone:626-403-6200
Practice Address - Fax:626-403-2580
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52154-0202081P2900X
CAC1354092081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine