Provider Demographics
NPI:1245764257
Name:HARRIS, TRAVIS WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WESLEY
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 1:315 NORTHLAKE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIANVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35759-2338
Mailing Address - Country:US
Mailing Address - Phone:706-331-6435
Mailing Address - Fax:
Practice Address - Street 1:301 GOVERNORS DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5123
Practice Address - Country:US
Practice Address - Phone:256-551-4500
Practice Address - Fax:256-551-4573
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL37604208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program