Provider Demographics
NPI:1780668285
Name:AGARWALA, BROJENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:BROJENDRA
Middle Name:
Last Name:AGARWALA
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 1:5841 S MARYLAND AVE
Mailing Address - Street 2:MC 4051
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1447
Mailing Address - Country:US
Mailing Address - Phone:773-795-4475
Mailing Address - Fax:773-702-2319
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:MC 4051
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-795-4475
Practice Address - Fax:773-702-2319
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360466682080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621679OtherBCBS OF IL
IL036046668Medicaid
C 42881Medicare UPIN
IL036046668Medicaid