Provider Demographics
NPI:1639276199
Name:HART, DAVID W (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
Last Name:HART
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 1:250 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 1:707 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2209
Practice Address - Country:US
Practice Address - Phone:812-334-5081
Practice Address - Fax:812-339-8344
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL28056208G00000X, 208G00000X
IN01058431A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009911293Medicaid
AL51541799OtherBCBS
IN200836050Medicaid
INP01176930Medicare PIN
IN257700OMedicare PIN
INM400056754Medicare PIN
AL051541799Medicare PIN
INP00833175Medicare PIN
ALI68509Medicare UPIN
IN200836050Medicaid