Provider Demographics
NPI:1043232333
Name:HARLESS, DEAN M (MD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:M
Last Name:HARLESS
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 1:3633 VALLEY VISTA ROAD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-3820
Mailing Address - Country:US
Mailing Address - Phone:615-269-4872
Mailing Address - Fax:
Practice Address - Street 1:3362 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109-2944
Practice Address - Country:US
Practice Address - Phone:901-701-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH046402207L00000X
KY37240207L00000X
MO2002000491207L00000X
TN24286207R00000X
GA12345207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6491516800Medicaid
KY000000578020OtherANTHEM BCBS
OHD29692Medicare UPIN
MO152360158Medicare PIN
KY00280076Medicare PIN
KY6491516800Medicaid