Healthcare Provider Details

I. General information

NPI: 1366443640
Provider Name (Legal Business Name): SUBODH K AGRAWAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 PRINCE AVE
ATHENS GA
30606-6032
US

IV. Provider business mailing address

2005 PRINCE AVE
ATHENS GA
30606-6032
US

V. Phone/Fax

Practice location:
  • Phone: 706-208-9700
  • Fax: 706-208-0806
Mailing address:
  • Phone: 706-208-9700
  • Fax: 706-208-0806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number028344
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number028344
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number028344
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: