Healthcare Provider Details

I. General information

NPI: 1366050742
Provider Name (Legal Business Name): FNU RAFAQAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: UNKNOWN RAFAQAT

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD
ELKHART IN
46514-2483
US

IV. Provider business mailing address

1325 GRINNELL ST APT 2705
GRANGER IN
46530-2304
US

V. Phone/Fax

Practice location:
  • Phone: 574-389-7393
  • Fax:
Mailing address:
  • Phone: 640-204-0192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number336798
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: