Healthcare Provider Details

I. General information

NPI: 1437827631
Provider Name (Legal Business Name): SAMIR CYRUS FARUQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2231 CAREW ST
FORT WAYNE IN
46805-4713
US

IV. Provider business mailing address

2200 RANDALLIA DR
FORT WAYNE IN
46805-4638
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-7765
  • Fax: 260-373-7770
Mailing address:
  • Phone: 260-373-7765
  • Fax: 260-373-7760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11025186A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: