Provider Demographics
NPI:1265545396
Name:HARRIS, KEITH A (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9090 PARK ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-9616
Mailing Address - Country:US
Mailing Address - Phone:239-936-3344
Mailing Address - Fax:239-936-5126
Practice Address - Street 1:9090 PARK ROYAL DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-9616
Practice Address - Country:US
Practice Address - Phone:239-936-3344
Practice Address - Fax:239-936-5126
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0065069207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF76680Medicare UPIN