Provider Demographics
NPI:1932142387
Name:HARRIS, TINA M (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:M
Last Name:HARRIS
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
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 1:714 N SENATE AVE
Practice Address - Street 2:STE EF205
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3763
Practice Address - Country:US
Practice Address - Phone:317-715-6402
Practice Address - Fax:317-715-6415
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010544872085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200351230Medicaid
INP00176959OtherRAILROAD MEDICARE
IN959090ZZZNMedicare PIN
IN219950VMedicare PIN
IN200351230Medicaid