Provider Demographics
NPI:1396740940
Name:HARRIS, DIANE ELISE (DO)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ELISE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:ELISE
Other - Last Name:ENNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5 EXECUTIVE CIR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3345
Mailing Address - Country:US
Mailing Address - Phone:912-691-1533
Mailing Address - Fax:912-691-1953
Practice Address - Street 1:4815 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5108
Practice Address - Country:US
Practice Address - Phone:910-452-1111
Practice Address - Fax:910-452-5897
Is Sole Proprietor?:No
Enumeration Date:2005-06-19
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1396740940OtherNPI
NC8939690Medicaid
NC0106FOtherBLUE CROSS BLUE SHIELD
NC8939690Medicaid
NCH05523Medicare UPIN