Provider Demographics
NPI:1912008590
Name:HARRIS, MICHAEL W (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 N UNIVERSITY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4465
Mailing Address - Country:US
Mailing Address - Phone:801-377-3933
Mailing Address - Fax:801-377-2779
Practice Address - Street 1:3325 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4465
Practice Address - Country:US
Practice Address - Phone:801-377-3933
Practice Address - Fax:801-377-2779
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180412-12042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE73672Medicare UPIN