Provider Demographics
NPI:1619035169
Name:HARRIS, DAVID MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
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 1:819 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-4434
Mailing Address - Country:US
Mailing Address - Phone:706-245-6177
Mailing Address - Fax:706-245-6242
Practice Address - Street 1:819 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-4434
Practice Address - Country:US
Practice Address - Phone:706-245-6177
Practice Address - Fax:706-245-6242
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00430064AMedicaid
040078OtherBCBS
GA08BDBZVMedicare ID - Type Unspecified
GA00430064AMedicaid