Provider Demographics
NPI:1033105994
Name:HARRIES, LARRY DEAN (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:HARRIES
Suffix:
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 1:307 ST JOHNS WAY
Mailing Address - Street 2:STE 4
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-743-8585
Mailing Address - Fax:208-743-0118
Practice Address - Street 1:307 ST JOHNS WAY
Practice Address - Street 2:STE 4
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-8585
Practice Address - Fax:208-743-0118
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3129207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000226400Medicaid
ID000226400Medicaid
1108978Medicare ID - Type Unspecified