Provider Demographics
NPI:1154336907
Name:RASUL, IFTIKHAR (MD)
Entity type:Individual
Prefix:
First Name:IFTIKHAR
Middle Name:
Last Name:RASUL
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 1:200 AVENUE F NE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881
Mailing Address - Country:US
Mailing Address - Phone:863-297-1702
Mailing Address - Fax:863-291-6084
Practice Address - Street 1:1201 1ST STREET SOUTH
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-297-1702
Practice Address - Fax:863-291-6084
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME886132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269810200Medicaid
FL269810200Medicaid
FL269810200Medicaid
431932Medicare ID - Type Unspecified