Healthcare Provider Details

I. General information

NPI: 1790470888
Provider Name (Legal Business Name): HERLIANI DWI PUTRI HALIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S LANDMARK AVE
BLOOMINGTON IN
47403-3239
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 812-330-3689
  • Fax: 812-355-3290
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01100633A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: