Provider Demographics
NPI:1598756074
Name:HARRISON, BOBBY E (MD)
Entity Type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:E
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 SW LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-1756
Mailing Address - Country:US
Mailing Address - Phone:386-365-4492
Mailing Address - Fax:386-487-5075
Practice Address - Street 1:1942 SW LITTLE RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-1756
Practice Address - Country:US
Practice Address - Phone:386-365-4492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87831207R00000X
FLME 878312085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274266700Medicaid
FLP00861454OtherRR MEDICARE
FLP009058928OtherRR MEDICARE
FLH54616Medicare UPIN