Provider Demographics
NPI:1962661215
Name:AGRAWAL, PANKAJ HARIBHAI (MD)
Entity Type:Individual
Prefix:DR
First Name:PANKAJ
Middle Name:HARIBHAI
Last Name:AGRAWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5615 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08110-1836
Mailing Address - Country:US
Mailing Address - Phone:856-488-1415
Mailing Address - Fax:856-488-1416
Practice Address - Street 1:5615 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08110-1836
Practice Address - Country:US
Practice Address - Phone:856-488-1415
Practice Address - Fax:856-488-1416
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA036575207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6889204Medicaid
NJ6889204Medicaid