Provider Demographics
NPI:1265464325
Name:HARRIS, DALE E (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:E
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 1:620 RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:REEDSPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97467
Mailing Address - Country:US
Mailing Address - Phone:541-271-2163
Mailing Address - Fax:541-271-4058
Practice Address - Street 1:620 RANCH ROAD
Practice Address - Street 2:
Practice Address - City:REEDSPORT
Practice Address - State:OR
Practice Address - Zip Code:97467
Practice Address - Country:US
Practice Address - Phone:541-271-2163
Practice Address - Fax:541-271-4058
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276263Medicaid
ORC91008Medicare UPIN
OR00WCGVWDMedicare PIN