Provider Demographics
NPI:1760663900
Name:AGRAWAL, HARSH VARDHAN (MD)
Entity type:Individual
Prefix:
First Name:HARSH VARDHAN
Middle Name:
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:PO BOX 708698
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-8698
Mailing Address - Country:US
Mailing Address - Phone:866-869-2395
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:1717 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4802
Practice Address - Country:US
Practice Address - Phone:208-455-3890
Practice Address - Fax:208-455-3895
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine