Provider Demographics
NPI:1154701860
Name:AGARWAL, MITALI
Entity type:Individual
Prefix:
First Name:MITALI
Middle Name:
Last Name:AGARWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 S ORANGE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2932
Mailing Address - Country:US
Mailing Address - Phone:321-842-9000
Mailing Address - Fax:321-843-6326
Practice Address - Street 1:1720 S ORANGE AVE STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2932
Practice Address - Country:US
Practice Address - Phone:321-842-9000
Practice Address - Fax:321-843-6326
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN22052207R00000X
FLME155845207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116429500Medicaid