Provider Demographics
NPI:1336156181
Name:HARRIS, WESLEY LEROY (MD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:LEROY
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 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:44045 RIVERSIDE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-5101
Practice Address - Country:US
Practice Address - Phone:703-858-8878
Practice Address - Fax:703-858-8170
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000169652208600000X
IL036114896208600000X
WV24649208600000X
VA0101263795208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810022393Medicaid
H30506Medicare UPIN
WV3810022393Medicaid