Provider Demographics
NPI:1265689863
Name:RAFATI, BOBAK (OD)
Entity Type:Individual
Prefix:
First Name:BOBAK
Middle Name:
Last Name:RAFATI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N VETERANS PKWY
Mailing Address - Street 2:#301
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3596
Mailing Address - Country:US
Mailing Address - Phone:309-663-2700
Mailing Address - Fax:
Practice Address - Street 1:3131 BROADWAY
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301
Practice Address - Country:US
Practice Address - Phone:217-223-7900
Practice Address - Fax:217-223-7999
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist