Provider Demographics
NPI:1588617401
Name:AGGARWAL, MINI (MD)
Entity Type:Individual
Prefix:
First Name:MINI
Middle Name:
Last Name:AGGARWAL
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 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-451-5855
Mailing Address - Fax:502-479-1425
Practice Address - Street 1:900 FAIRDALE RD
Practice Address - Street 2:
Practice Address - City:FAIRDALE
Practice Address - State:KY
Practice Address - Zip Code:40118-9731
Practice Address - Country:US
Practice Address - Phone:502-366-8778
Practice Address - Fax:502-366-9163
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64055494Medicaid
KYG82979Medicare UPIN
KY64055494Medicaid
KY00546170Medicare Oscar/Certification