Provider Demographics
NPI:1124011689
Name:HARRIS, ETHAN GEOFFREY (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:GEOFFREY
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 999
Mailing Address - Street 2:13437 ANTELOPE TRAIL
Mailing Address - City:OREGON HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95962-0999
Mailing Address - Country:US
Mailing Address - Phone:530-692-0802
Mailing Address - Fax:
Practice Address - Street 1:1119 E MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3009
Practice Address - Country:US
Practice Address - Phone:707-469-4610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG187272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G187271Medicare ID - Type UnspecifiedPRACTICE LOCATION 2
CA00G187270Medicare ID - Type UnspecifiedPRACTICE LOCATION 1
CAA40401Medicare UPIN
CA00G187272Medicare ID - Type UnspecifiedPRACTICE LOCATION 3