Provider Demographics
NPI:1548201106
Name:HARRIS, WELDON (MD)
Entity Type:Individual
Prefix:
First Name:WELDON
Middle Name:
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 1:625 NE LAKE POINTE DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1193
Mailing Address - Country:US
Mailing Address - Phone:816-373-1142
Mailing Address - Fax:816-373-9222
Practice Address - Street 1:17500 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 5
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1823
Practice Address - Country:US
Practice Address - Phone:816-373-1142
Practice Address - Fax:816-373-9222
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO35496208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG13096Medicare UPIN