Healthcare Provider Details

I. General information

NPI: 1740470210
Provider Name (Legal Business Name): CARL T RATLIFF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 BEACON ST
FORT WAYNE IN
46805-4749
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-8000
  • Fax: 260-373-8034
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number02004483A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: