Provider Demographics
NPI:1083616775
Name:HARRIS, GREGG MICHAEL (DPM)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:MICHAEL
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9980 CENTRAL PARK BLVD N
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1703
Mailing Address - Country:US
Mailing Address - Phone:561-488-3338
Mailing Address - Fax:561-488-1540
Practice Address - Street 1:9980 CENTRAL PARK BLVD N
Practice Address - Street 2:SUITE 106
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1703
Practice Address - Country:US
Practice Address - Phone:561-488-3338
Practice Address - Fax:561-488-1540
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO-0001441213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT55538Medicare UPIN
FL87776ZMedicare ID - Type Unspecified
FLK1761Medicare ID - Type Unspecified