Provider Demographics
NPI:1215011846
Name:HARRIS, ROBERT BOATWRIGHT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BOATWRIGHT
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 1:200 COMMODORE ST
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-2903
Mailing Address - Country:US
Mailing Address - Phone:620-450-1186
Mailing Address - Fax:
Practice Address - Street 1:124 COMMODORE ST STE B
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-2995
Practice Address - Country:US
Practice Address - Phone:620-672-6454
Practice Address - Fax:620-672-3488
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00019179208600000X
KS04-43413208600000X
MS12574208600000X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000033694Medicaid
MS00110609Medicaid
AL051033694OtherBC/BS OF AL
AL051033694OtherBC/BS OF AL
ALE46441Medicare UPIN