Healthcare Provider Details

I. General information

NPI: 1861599300
Provider Name (Legal Business Name): SUDEEPTA A RAKHRA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUDEEPTA A BHARGAVE

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S NAPPANEE ST
ELKHART IN
46514-2066
US

IV. Provider business mailing address

PO BOX 2968
ELKHART IN
46515-2968
US

V. Phone/Fax

Practice location:
  • Phone: 574-296-3200
  • Fax: 574-296-3921
Mailing address:
  • Phone: 574-296-3390
  • Fax: 574-296-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036112090
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003431A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: