Provider Demographics
NPI:1710980677
Name:HARRIS, TODD S (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:S
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:PO BOX 12139
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-5053
Mailing Address - Country:US
Mailing Address - Phone:949-221-0136
Mailing Address - Fax:949-387-1136
Practice Address - Street 1:4501 BIRCH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-221-0136
Practice Address - Fax:949-387-1136
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105121208600000X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI171098067Medicaid
MI171098067Medicaid