Basic Information
Provider Information | |||||||||
NPI: | 1396042107 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AGARWAL | ||||||||
FirstName: | NEELAM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GARG | ||||||||
OtherFirstName: | NEELAM | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 100 KINGS HIGHWAY S | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146175504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157875100 | ||||||||
FaxNumber: | 3157875221 | ||||||||
Practice Location | |||||||||
Address1: | 200 NORTH STREET; SUITE 101 | ||||||||
Address2: |   | ||||||||
City: | GENEVA | ||||||||
State: | NY | ||||||||
PostalCode: | 144561561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157875100 | ||||||||
FaxNumber: | 3157875221 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2011 | ||||||||
LastUpdateDate: | 04/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 303902 | NY | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1396042107 | 01 |   | MEDICARE | OTHER | 500632565 | 05 | OR |   | MEDICAID |