Provider Demographics
NPI:1326038647
Name:HARRIS, JEFFREY EARL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EARL
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 1:1530 S OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3023
Mailing Address - Country:US
Mailing Address - Phone:213-747-5039
Mailing Address - Fax:
Practice Address - Street 1:1530 S OLIVE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3023
Practice Address - Country:US
Practice Address - Phone:213-747-5039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38219207R00000X
CAG156585207R00000X
RIMD11997207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7058374Medicaid
MAJ31197OtherBCBS MA
MA0189561Medicaid
MA038219OtherTUFTS HEALTH PLAN
MA038219OtherTUFTS HEALTH PLAN
RI7058374Medicaid
MAJ31197OtherBCBS MA