Provider Demographics
NPI:1942232285
Name:HARRIS, JEFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
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 1:325 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4437
Mailing Address - Country:US
Mailing Address - Phone:208-798-8500
Mailing Address - Fax:208-798-8530
Practice Address - Street 1:325 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4437
Practice Address - Country:US
Practice Address - Phone:208-798-8500
Practice Address - Fax:208-798-8530
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034232207R00000X
IDM-9259207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806974300Medicaid
WA8289035Medicaid
G79687Medicare UPIN
WA8806659Medicare ID - Type UnspecifiedMEDICARE OF WAHINGTON
WA8289035Medicaid