Provider Demographics
NPI:1124180989
Name:EUGENE HARRIS MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:EUGENE HARRIS MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-423-9825
Mailing Address - Street 1:444 SO SAN VINCENTE BLVD
Mailing Address - Street 2:SUITE 603
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4165
Mailing Address - Country:US
Mailing Address - Phone:310-423-9889
Mailing Address - Fax:310-423-9891
Practice Address - Street 1:444 SO SAN VINCENTE BLVD
Practice Address - Street 2:SUITE 603
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4165
Practice Address - Country:US
Practice Address - Phone:310-423-9889
Practice Address - Fax:310-423-9891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG4367207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000G43670Medicaid
CAP2260601OtherOXFORD
CA0004123611OtherAETNA
CA000G43670OtherBS
A56462Medicare UPIN
CAP2260601OtherOXFORD