Provider Demographics
NPI:1013953876
Name:HARRIS, JERRY WAYNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WAYNE
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DPM
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 39721
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27438-9721
Mailing Address - Country:US
Mailing Address - Phone:336-638-3700
Mailing Address - Fax:
Practice Address - Street 1:5323 FOX COVE LN
Practice Address - Street 2:U
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-5961
Practice Address - Country:US
Practice Address - Phone:336-638-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC326213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890808EMedicaid
NCU23707Medicare UPIN
NC890808EMedicaid