Healthcare Provider Details

I. General information

NPI: 1194565903
Provider Name (Legal Business Name): SHRAIY AGRAWAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 07/22/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200B VILLAGE WALK
GUILFORD CT
06437-2745
US

IV. Provider business mailing address

375 E MAIN ST UNIT 9
BRANFORD CT
06405-2963
US

V. Phone/Fax

Practice location:
  • Phone: 203-458-2020
  • Fax:
Mailing address:
  • Phone: 347-406-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number009990
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3350
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: