Provider Demographics
NPI:1861489098
Name:AGARWAL, SUMAN (MD)
Entity Type:Individual
Prefix:
First Name:SUMAN
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 1:4646 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0102
Mailing Address - Country:US
Mailing Address - Phone:951-774-2800
Mailing Address - Fax:951-774-2846
Practice Address - Street 1:4646 BROCKTON AVE
Practice Address - Street 2:STE 203
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0102
Practice Address - Country:US
Practice Address - Phone:951-774-2744
Practice Address - Fax:951-774-2740
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E13969Medicare ID - Type Unspecified