Provider Demographics
NPI:1831285618
Name:AGRAWAL, RUCHIR
Entity Type:Individual
Prefix:
First Name:RUCHIR
Middle Name:
Last Name:AGRAWAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 GENEVIEVE CT
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269
Mailing Address - Country:US
Mailing Address - Phone:678-400-6650
Mailing Address - Fax:678-669-2401
Practice Address - Street 1:115 GENEVIEVE CT
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269
Practice Address - Country:US
Practice Address - Phone:678-400-6650
Practice Address - Fax:678-669-2401
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43561208000000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003130521D&EMedicaid
WI34123200Medicaid
WIH45788Medicare UPIN
000001467Medicare ID - Type Unspecified