Provider Demographics
NPI:1740283415
Name:HARRIS, GARNET R (MD)
Entity type:Individual
Prefix:DR
First Name:GARNET
Middle Name:R
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:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122
Mailing Address - Country:US
Mailing Address - Phone:317-718-0044
Mailing Address - Fax:317-745-5219
Practice Address - Street 1:7 MANOR DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122
Practice Address - Country:US
Practice Address - Phone:317-718-0044
Practice Address - Fax:317-745-5219
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100083560Medicaid
IN080114205OtherMEDICARE RAILROAD
IN10782527OtherCAQH
IN000000092260OtherBLUE CROSS BLUE SHIELD
IN4289645OtherAETNA
INM400029295OtherMEDICARE
IN080114205OtherMEDICARE RAILROAD
INC24324Medicare UPIN
IN080114205Medicare PIN
IN10782527OtherCAQH
IN100083560Medicaid