Provider Demographics
NPI:1629184692
Name:AGARWAL, CHAITANYA K (MD)
Entity Type:Individual
Prefix:
First Name:CHAITANYA
Middle Name:K
Last Name:AGARWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 940
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951-0940
Mailing Address - Country:US
Mailing Address - Phone:304-466-1366
Mailing Address - Fax:304-466-1366
Practice Address - Street 1:1501 TERRACE STREET
Practice Address - Street 2:SUMMERS COMMUNITY CLINIC
Practice Address - City:HINTON
Practice Address - State:WV
Practice Address - Zip Code:25951-0940
Practice Address - Country:US
Practice Address - Phone:304-466-1366
Practice Address - Fax:304-466-1366
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11042207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0094908000Medicaid
D49361Medicare UPIN
WV0094908000Medicaid
WV0439950001Medicare NSC