Provider Demographics
NPI:1679678627
Name:HARRIS, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
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 1:19 VALLEY GREENS DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3634
Mailing Address - Country:US
Mailing Address - Phone:516-374-8606
Mailing Address - Fax:
Practice Address - Street 1:19333 BEAR VALLEY ROAD
Practice Address - Street 2:SUITE # 101 AND 102
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308
Practice Address - Country:US
Practice Address - Phone:760-241-6666
Practice Address - Fax:760-241-7575
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036288207R00000X
CAG382541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010036288CT05OtherANTHEM