Provider Demographics
NPI:1790470888
Name:HALIM, HERLIANI DWI PUTRI (MD)
Entity Type:Individual
Prefix:
First Name:HERLIANI
Middle Name:DWI PUTRI
Last Name:HALIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 CHICAGO AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1364
Mailing Address - Country:US
Mailing Address - Phone:510-542-7368
Mailing Address - Fax:
Practice Address - Street 1:1233 CHICAGO AVE APT 11
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1364
Practice Address - Country:US
Practice Address - Phone:510-542-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program