Provider Demographics
NPI:1255396255
Name:HARRISON, DAVID THOMAS (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:THOMAS
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8314 EAGLE CREST LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-9528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3660 GUION RD
Practice Address - Street 2:STE 330
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-1697
Practice Address - Country:US
Practice Address - Phone:317-923-1033
Practice Address - Fax:317-927-7426
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000816208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01424321OtherRAIL ROAD PTAN
IN100218030Medicaid
IN000000727646OtherBCBS
IN100218030AMedicaid
IN100218030AMedicaid
INM400052451Medicare PIN
IN266180445Medicare PIN