Provider Demographics
NPI:1598788697
Name:HARRIS, SALLY L (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:L
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14017 WIND MOUNTAIN RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-6562
Mailing Address - Country:US
Mailing Address - Phone:505-228-5952
Mailing Address - Fax:505-884-1671
Practice Address - Street 1:4600 JEFFERSON LN NE
Practice Address - Street 2:SUITE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2134
Practice Address - Country:US
Practice Address - Phone:505-884-4406
Practice Address - Fax:505-884-1671
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM982842084N0400X
NM98-2842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ3855Medicaid
G88284Medicare UPIN