Provider Demographics
NPI:1629155643
Name:RAGHIB, ENDER G (MD)
Entity Type:Individual
Prefix:DR
First Name:ENDER
Middle Name:G
Last Name:RAGHIB
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 1:325 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-4248
Mailing Address - Country:US
Mailing Address - Phone:701-364-2647
Mailing Address - Fax:
Practice Address - Street 1:3290 20TH ST S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-5923
Practice Address - Country:US
Practice Address - Phone:701-478-4722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9514208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN395461700Medicaid
ND12730Medicaid
NDN3629Medicare ID - Type Unspecified
ND12730Medicaid