Provider Demographics
NPI:1326119652
Name:HARRIS, GARY SAMUEL (PT, OCS)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:SAMUEL
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4175 VETERANS MEMORIAL HWY
Mailing Address - Street 2:STE 202
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7639
Mailing Address - Country:US
Mailing Address - Phone:856-797-6778
Mailing Address - Fax:856-797-8011
Practice Address - Street 1:773 E ROUTE 70
Practice Address - Street 2:STE E110
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2371
Practice Address - Country:US
Practice Address - Phone:856-282-0339
Practice Address - Fax:856-334-8654
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ40QA00312500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ427489Medicare ID - Type Unspecified