Provider Demographics
NPI:1316252414
Name:SANJAY AGARWAL PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:SANJAY AGARWAL PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:AGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FCCP, FAASM
Authorized Official - Phone:408-942-0300
Mailing Address - Street 1:995 MONTAGUE EXPY STE 218
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-6885
Mailing Address - Country:US
Mailing Address - Phone:408-942-0300
Mailing Address - Fax:408-890-7298
Practice Address - Street 1:995 MONTAGUE EXPY STE 218
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-6885
Practice Address - Country:US
Practice Address - Phone:408-942-0300
Practice Address - Fax:408-890-7298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104257261QH0100X, 261QS1200X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADP377AMedicare UPIN