Provider Demographics
NPI:1689730905
Name:HARRIS, WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
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 1:2000 HAMILTON ST
Mailing Address - Street 2:RODIN PLACE SUITE 306
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3814
Mailing Address - Country:US
Mailing Address - Phone:215-545-5001
Mailing Address - Fax:215-545-5763
Practice Address - Street 1:255 S 17TH ST
Practice Address - Street 2:SUITE 1002
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6231
Practice Address - Country:US
Practice Address - Phone:215-545-5001
Practice Address - Fax:215-545-5763
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039446E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1110571Medicaid
PA4467G08Medicare ID - Type Unspecified
PAC34271Medicare UPIN