Provider Demographics
NPI:1033596176
Name:HARRIS, BENNETT (DO)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3365 S 103RD ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-4161
Mailing Address - Country:US
Mailing Address - Phone:414-228-4800
Mailing Address - Fax:262-432-9004
Practice Address - Street 1:3365 S 103RD ST STE 210
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4161
Practice Address - Country:US
Practice Address - Phone:414-228-4800
Practice Address - Fax:262-432-9004
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1541232084P0804X
OH34.0147102084P0804X
WI742252084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1033596176Medicaid