Provider Demographics
NPI:1447419858
Name:LASISI, RAUFU ADEFEMI (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUFU
Middle Name:ADEFEMI
Last Name:LASISI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8910 PURDUE RD
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-948-0762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013709A207R00000X
IN01067846A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200311740HOtherHPN MEDICAID GROUP#/LOCATION
IN200980210Medicaid
205110OtherHPN MEDICARE GROUP#
IN000000708549OtherANTHEM PROVIDER NUMBER / TIN 35-2030653
000000672592OtherHPN ANTHEM PIN#
IN200980210Medicaid
000000672592OtherHPN ANTHEM PIN#
IN200311740HOtherHPN MEDICAID GROUP#/LOCATION