Healthcare Provider Details

I. General information

NPI: 1326458589
Provider Name (Legal Business Name): ANANT AGARWALLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N MAIN STREET EXT
WALLINGFORD CT
06492-2400
US

IV. Provider business mailing address

30 WATERCHASE DR
ROCKY HILL CT
06067-2110
US

V. Phone/Fax

Practice location:
  • Phone: 203-886-0036
  • Fax: 203-886-0072
Mailing address:
  • Phone: 860-257-4131
  • Fax: 860-457-4519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number70508
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: