Individual
MIMILY HARSONO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
877 JEFFERSON AVE, MEMPHIS, TN 38103-2807
(901) 545-7100
Mailing address
1068 CRESTHAVEN RD STE 300, MEMPHIS, TN 38119-0809
Taxonomy
Speciality
Code
Description
License number
State
2080N0001X
Neonatal-Perinatal Medicine Physician
Primary
50025
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00179412A
—
GA
05
—
02507295
—
MS
05
—
1003137571
—
MI
05
—
1003137571
—
MO
05
—
1532008
—
TN
05
—
177423
—
AL
05
—
197560001
—
AR
Enumeration date
06/18/2010
Last updated
02/25/2025
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