Provider Demographics
NPI:1649235219
Name:HARRIS, VICTORIA V (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:V
Last Name:HARRIS
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 1:100 E. MAIN STREET, SUITE C
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-6041
Mailing Address - Country:US
Mailing Address - Phone:541-789-4728
Mailing Address - Fax:541-789-4765
Practice Address - Street 1:100 E. MAIN STREET, SUITE C
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-6041
Practice Address - Country:US
Practice Address - Phone:541-789-4728
Practice Address - Fax:541-789-4765
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22278207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288482Medicaid
ORH00541Medicare UPIN
OR106674Medicare ID - Type Unspecified