Provider Demographics
NPI:1740282474
Name:SOOFI-SIAVASH, RAFI (MD)
Entity type:Individual
Prefix:DR
First Name:RAFI
Middle Name:
Last Name:SOOFI-SIAVASH
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 1:1941 LIMESTONE RD
Mailing Address - Street 2:STE. 203
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5400
Mailing Address - Country:US
Mailing Address - Phone:302-999-1644
Mailing Address - Fax:302-999-1686
Practice Address - Street 1:1941 LIMESTONE RD
Practice Address - Street 2:STE. 203
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5400
Practice Address - Country:US
Practice Address - Phone:302-999-1644
Practice Address - Fax:302-999-1686
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10001828174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000020801Medicaid
DE0751750001Medicare NSC
DE0000020801Medicaid
DEB66492Medicare UPIN