Provider Demographics
NPI:1649262577
Name:HARRIS, MARK I (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:I
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 1:6300 HOSPITAL PKWY
Mailing Address - Street 2:SUITE 260
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1828
Mailing Address - Country:US
Mailing Address - Phone:770-454-4685
Mailing Address - Fax:770-454-4690
Practice Address - Street 1:6300 HOSPITAL PKWY
Practice Address - Street 2:SUITE 260
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1828
Practice Address - Country:US
Practice Address - Phone:770-454-4685
Practice Address - Fax:770-454-4690
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00371115DMedicaid
GA13BDDHNMedicare ID - Type Unspecified
GA00371115DMedicaid