Provider Demographics
NPI:1174723290
Name:AGRAWAL, PRANJAL M (MD)
Entity type:Individual
Prefix:
First Name:PRANJAL
Middle Name:M
Last Name:AGRAWAL
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 1:102 S HENNEPIN AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3013
Mailing Address - Country:US
Mailing Address - Phone:815-285-8535
Mailing Address - Fax:815-285-8922
Practice Address - Street 1:102 S HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3013
Practice Address - Country:US
Practice Address - Phone:815-284-7733
Practice Address - Fax:815-288-1487
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-118796208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL80020007OtherMEDICARE PTAN
IL036-118796OtherILLINOIS PHYSICIAN & SURG
IL036118796Medicaid
IL336-080021OtherILLINOIS CONTROLLED SUBST
ILK40163OtherMEDICARE PTAN