Provider Demographics
NPI:1023024718
Name:HARRIS, WILLIAM GIBSON JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GIBSON
Last Name:HARRIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-9706
Mailing Address - Country:US
Mailing Address - Phone:856-478-2160
Mailing Address - Fax:707-667-2159
Practice Address - Street 1:79 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-9706
Practice Address - Country:US
Practice Address - Phone:856-478-2160
Practice Address - Fax:707-667-2159
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22652207Q00000X
NC14678207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1638807Medicaid
D96412Medicare UPIN
NJ1638807Medicaid