Provider Demographics
NPI:1235472531
Name:HARRIS, ELI J (MD)
Entity Type:Individual
Prefix:
First Name:ELI
Middle Name:J
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-3760
Mailing Address - Fax:208-302-3768
Practice Address - Street 1:4424 E FLAMINGO
Practice Address - Street 2:STE 310
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-302-3760
Practice Address - Fax:208-302-3768
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14151207LP2900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0001969059Medicaid