Provider Demographics
NPI:1376001479
Name:HARRIS, BLAIR WALTER (DO)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:WALTER
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:509 OLDE WATERFORD WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4126
Mailing Address - Country:US
Mailing Address - Phone:910-631-0301
Mailing Address - Fax:910-292-1230
Practice Address - Street 1:509 OLDE WATERFORD WAY STE 103
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4126
Practice Address - Country:US
Practice Address - Phone:910-631-0301
Practice Address - Fax:910-292-1230
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-02190207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery