Provider Demographics
NPI:1558348896
Name:HARRIS, CHARLES R (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:HARRIS
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:PO BOX 869
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46061-0869
Mailing Address - Country:US
Mailing Address - Phone:317-770-6900
Mailing Address - Fax:317-770-6911
Practice Address - Street 1:509 N PERU ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IN
Practice Address - Zip Code:46034-9499
Practice Address - Country:US
Practice Address - Phone:317-984-9311
Practice Address - Fax:317-984-7302
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035173A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100126140Medicaid
Q0085361OtherSHO
IN000000081519OtherANTHEM
IN177280TTMedicare PIN
IN110020929Medicare PIN
IN000000081519OtherANTHEM