Provider Demographics
NPI:1073590410
Name:HARRIS, CHARLES RUSSELL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RUSSELL
Last Name:HARRIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2400 BELLEVUE RD
Mailing Address - Street 2:SUITE 21-A
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2885
Mailing Address - Country:US
Mailing Address - Phone:478-275-7202
Mailing Address - Fax:478-274-8418
Practice Address - Street 1:101 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029-1698
Practice Address - Country:US
Practice Address - Phone:478-994-5281
Practice Address - Fax:478-994-9781
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2015-04-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA019692207NS0135X, 207N00000X, 207NP0225X, 208D00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136057Medicaid
GA003136057Medicaid
GAD45571Medicare UPIN
GA202I070609Medicare PIN