Provider Demographics
NPI:1710920012
Name:AGARWAL, SMITA (MD)
Entity Type:Individual
Prefix:
First Name:SMITA
Middle Name:
Last Name:AGARWAL
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:S-4947 LAKESHORE ROAD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5615
Mailing Address - Country:US
Mailing Address - Phone:716-627-4407
Mailing Address - Fax:716-627-1174
Practice Address - Street 1:S-4947 LAKESHORE ROAD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-5615
Practice Address - Country:US
Practice Address - Phone:716-627-4407
Practice Address - Fax:716-627-1174
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1574611208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00958618Medicaid