Provider Demographics
NPI:1255340865
Name:HARRIS, EVAN WYNNE (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:WYNNE
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 1:7474 GREENWAY CENTER DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3500
Mailing Address - Country:US
Mailing Address - Phone:855-830-8346
Mailing Address - Fax:
Practice Address - Street 1:622 HEBRON AVE STE 103
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5003
Practice Address - Country:US
Practice Address - Phone:727-452-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME657452085P0229X
VA01012575532085R0204X
CT537392085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG01618Medicare PIN
VA392175YAY8Medicare PIN