Basic Information
| Provider Information | |||||||||
| NPI: | 1588617401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGGARWAL | ||||||||
| FirstName: | MINI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6801 DIXIE HWY | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402583913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024515855 | ||||||||
| FaxNumber: | 5024791425 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 FAIRDALE RD | ||||||||
| Address2: | |||||||||
| City: | FAIRDALE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401189731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023668778 | ||||||||
| FaxNumber: | 5023669163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32308 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64055494 | 05 | KY | MEDICAID |