Provider Demographics
NPI:1699736298
Name:AGRAWAL, RAJENDRA MOHAN (MD)
Entity type:Individual
Prefix:DR
First Name:RAJENDRA
Middle Name:MOHAN
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 1:408 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569
Mailing Address - Country:US
Mailing Address - Phone:585-786-2540
Mailing Address - Fax:585-786-7958
Practice Address - Street 1:408 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569
Practice Address - Country:US
Practice Address - Phone:585-786-2540
Practice Address - Fax:585-786-7958
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00748747Medicaid
NY087741Medicare ID - Type UnspecifiedMEDICARE
NY00748747Medicaid