Provider Demographics
NPI:1962467639
Name:HARRIS, TED A (MD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:A
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 1:2301 SOUTH 65 HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-3702
Mailing Address - Country:US
Mailing Address - Phone:660-886-6677
Mailing Address - Fax:660-886-3346
Practice Address - Street 1:2301 SOUTH 65 HIGHWAY
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3702
Practice Address - Country:US
Practice Address - Phone:660-886-6677
Practice Address - Fax:660-886-3346
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22265207V00000X
MO2011010497207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
124882OtherHEALTH ALLIANCE
421527584-19OtherJOHN DEERE
A02331Medicare UPIN