Healthcare Provider Details

I. General information

NPI: 1174723290
Provider Name (Legal Business Name): PRANJAL M AGRAWAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S HENNEPIN AVE
DIXON IL
61021-3013
US

IV. Provider business mailing address

102 S HENNEPIN AVE
DIXON IL
61021-3013
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-7733
  • Fax: 815-288-1487
Mailing address:
  • Phone: 815-285-8535
  • Fax: 815-285-8922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-118796
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036-118796
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: