Basic Information
Provider Information | |||||||||
NPI: | 1891041125 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AGARWAL | ||||||||
FirstName: | POOJA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3400 OLD MILTON PKWY STE C200 | ||||||||
Address2: |   | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300053742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704421911 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3400 OLD MILTON PKWY STE 270 | ||||||||
Address2: |   | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300053707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704421911 | ||||||||
FaxNumber: | 7704420306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2012 | ||||||||
LastUpdateDate: | 04/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 73097 | GA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 175378 | 05 | AL |   | MEDICAID | 102I088156 | 01 | AL | MEDICARE | OTHER | QMP000004309418 | 01 | AL | HEALTH SPRINGS | OTHER | 511-65349 | 01 | AL | BCBS | OTHER | Z29293 | 01 | AL | VIVA | OTHER |