Provider Demographics
NPI:1972636983
Name:HARRIS, CHARLES D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
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 22696
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-2696
Mailing Address - Country:US
Mailing Address - Phone:423-870-1662
Mailing Address - Fax:423-877-4845
Practice Address - Street 1:5000 ALPHA LN
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4054
Practice Address - Country:US
Practice Address - Phone:423-870-1662
Practice Address - Fax:423-877-4845
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000011415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN080163948OtherMEDICARE RR
TN3168293Medicaid
TN3168293Medicaid
TN31682980Medicare PIN
TN080163948OtherMEDICARE RR
TN3720420Medicare PIN