Provider Demographics
NPI:1114004959
Name:HARRIS, EDDIE
Entity Type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3890 REDWINE RD SW
Mailing Address - Street 2:SUITE 212
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5582
Mailing Address - Country:US
Mailing Address - Phone:404-349-1115
Mailing Address - Fax:404-349-0141
Practice Address - Street 1:3890 REDWINE RD SW
Practice Address - Street 2:SUITE 212
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5582
Practice Address - Country:US
Practice Address - Phone:404-349-1115
Practice Address - Fax:404-349-0141
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053235207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA954251OtherBCBS
GA139155698DMedicaid
GA7303815OtherAETNA
GAH93439Medicare UPIN
GA139155698DMedicaid