Provider Demographics
NPI:1407053895
Name:HARRIS, RICHARD WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WAYNE
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 1:4301 N STAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:2380 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5078
Practice Address - Country:US
Practice Address - Phone:702-576-9608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.119357207P00000X
MI4301093310207P00000X
NV14479207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036119357Medicaid
IL036119357Medicaid