Provider Demographics
NPI:1598760001
Name:HARRIS, STEPHEN D (DPM)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4839
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-4839
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:3260 EAGLE PARK DR NE
Practice Address - Street 2:SUITE 116
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4569
Practice Address - Country:US
Practice Address - Phone:616-957-2088
Practice Address - Fax:855-665-5636
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001348213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4853950100OtherBLUE CROSS BLUE SHIELD #
MI4348724Medicaid
MIP00019530OtherMEDICARE RAILROAD
MI4348724Medicaid
MI4677480001Medicare NSC
MIP00019530OtherMEDICARE RAILROAD