Provider Demographics
NPI:1093923872
Name:HARRIS, JUSTIN RAY SR (SFIDC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:RAY
Last Name:HARRIS
Suffix:SR
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8549 CULFOR CRESCENT
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23503
Mailing Address - Country:US
Mailing Address - Phone:757-839-3185
Mailing Address - Fax:
Practice Address - Street 1:581 'A' STREET
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-2133
Practice Address - Country:US
Practice Address - Phone:757-443-0026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman