Provider Demographics
NPI:1619935731
Name:HARRIS, TERRI L (MD)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:L
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:L
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2625 E 62ND STREET
Practice Address - Street 2:STE 2010
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3191
Practice Address - Country:US
Practice Address - Phone:317-251-6121
Practice Address - Fax:317-257-0390
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032792A208000000X
IN01032792208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100226560Medicaid
IN000000086793OtherANTHEM
IN000000086793OtherANTHEM
IN100226560Medicaid
IN715530CCMedicare PIN