Provider Demographics
NPI:1134192644
Name:HARRIS, ANDRE TODD SR (MD)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:TODD
Last Name:HARRIS
Suffix:SR
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 1:1 ELIZABETH PL
Mailing Address - Street 2:5TH FLOOR, STE. M
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3445
Mailing Address - Country:US
Mailing Address - Phone:937-228-4942
Mailing Address - Fax:
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:5TH FLR, STE. M
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-228-4942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086818207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2649405Medicaid
OH680624274OtherTIN
OHI53580Medicare UPIN
OH2649405Medicaid