Provider Demographics
NPI:1154314029
Name:HARRIS, MATTHEW WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WAYNE
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 1:5900 WALDON RD STE D
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4806
Mailing Address - Country:US
Mailing Address - Phone:810-424-2411
Mailing Address - Fax:
Practice Address - Street 1:5900 WALDON RD STE D
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4806
Practice Address - Country:US
Practice Address - Phone:810-424-2411
Practice Address - Fax:810-249-4420
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051360207R00000X
WV16778208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1801405000Medicaid
KY64699630Medicaid
OH0868575Medicaid
F21193Medicare UPIN
KY64699630Medicaid