Healthcare Provider Details

I. General information

NPI: 1013911593
Provider Name (Legal Business Name): RAFAT H ANSARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 HOLY CROSS PKWY
MISHAWAKA IN
46545-1470
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 574-234-5123
  • Fax: 574-282-2813
Mailing address:
  • Phone: 574-334-5390
  • Fax: 574-334-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301052476
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number01028409A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number01028409A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: