Healthcare Provider Details

I. General information

NPI: 1356085518
Provider Name (Legal Business Name): RAFI FASIHUDDIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 W LIBERTY ST
FARMINGTON MO
63640-1921
US

IV. Provider business mailing address

PO BOX 959354
SAINT LOUIS MO
63195-9354
US

V. Phone/Fax

Practice location:
  • Phone: 573-760-8259
  • Fax: 573-760-8259
Mailing address:
  • Phone: 573-760-8259
  • Fax: 573-705-1247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number20250030175
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: