Provider Demographics
NPI:1134105968
Name:HARRIS, MATTHEW R (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:R
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 W MAIN ST STE 503
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2058
Mailing Address - Country:US
Mailing Address - Phone:220-564-1778
Mailing Address - Fax:220-564-1779
Practice Address - Street 1:1272 W MAIN ST STE 503
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2058
Practice Address - Country:US
Practice Address - Phone:220-564-1778
Practice Address - Fax:220-564-1779
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.008347207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050491Medicaid
OH0050491Medicaid
OHH016405Medicare PIN