Provider Demographics
NPI:1851313068
Name:BAUER, NERISSA S (MD)
Entity Type:Individual
Prefix:DR
First Name:NERISSA
Middle Name:S
Last Name:BAUER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NERISSA
Other - Middle Name:B
Other - Last Name:SAN LUIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4000 W 106TH ST STE 125-196
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7720
Mailing Address - Country:US
Mailing Address - Phone:317-660-5205
Mailing Address - Fax:866-468-0406
Practice Address - Street 1:2159 GLEBE ST STE 270
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7372
Practice Address - Country:US
Practice Address - Phone:317-660-5205
Practice Address - Fax:866-468-0406
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062492A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200827540Medicaid
IN068010125Medicare PIN