Provider Demographics
NPI:1710912894
Name:AGRAWAL, SANJAY (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:AGRAWAL
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 1:3209 S 23RD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1602
Mailing Address - Country:US
Mailing Address - Phone:253-272-8148
Mailing Address - Fax:253-404-0506
Practice Address - Street 1:3209 S 23RD ST
Practice Address - Street 2:STE 340
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1602
Practice Address - Country:US
Practice Address - Phone:253-272-8148
Practice Address - Fax:253-404-0506
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040323207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00040323OtherLICENSE
WA8519878Medicaid
WAG8873590Medicare PIN
WA001045700Medicare PIN
WAG8851596Medicare PIN
WAMD00040323OtherLICENSE
WA8851594Medicare PIN
WA000188100Medicare PIN
WAP00671966Medicare PIN
WAG8851595Medicare PIN
WAG8851597Medicare PIN
WAG8873591Medicare PIN
WAG8880511Medicare PIN