Provider Demographics
NPI:1225464837
Name:HARRIS, STEPHEN MITCHELL (IDMT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MITCHELL
Last Name:HARRIS
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 SPRUCE ST
Mailing Address - Street 2:PCS BOX 1000
Mailing Address - City:LANGLEY AFB
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2800
Mailing Address - Country:US
Mailing Address - Phone:757-848-8272
Mailing Address - Fax:
Practice Address - Street 1:49 SPRUCE ST
Practice Address - Street 2:PCS BOX 1000
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2800
Practice Address - Country:US
Practice Address - Phone:757-848-8272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians