Healthcare Provider Details

I. General information

NPI: 1174733059
Provider Name (Legal Business Name): RENUKA AGRAWAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 COLUMBIA
ALISO VIEJO CA
92656-1460
US

IV. Provider business mailing address

31 COLUMBIA
ALISO VIEJO CA
92656-1460
US

V. Phone/Fax

Practice location:
  • Phone: 949-643-7460
  • Fax: 949-425-5865
Mailing address:
  • Phone: 949-643-7460
  • Fax: 949-425-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberA102411
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA102411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: