Healthcare Provider Details

I. General information

NPI: 1104082809
Provider Name (Legal Business Name): MOHAMED FARHAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 S MAIN ST SUITE 301
CROWN POINT IN
46307-3676
US

IV. Provider business mailing address

100 E WAYNE ST STE 510
SOUTH BEND IN
46601-2349
US

V. Phone/Fax

Practice location:
  • Phone: 219-661-1640
  • Fax: 219-661-8066
Mailing address:
  • Phone: 574-334-5390
  • Fax: 574-334-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-116126
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number01066282A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301095492
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number01066282A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: