Provider Demographics
NPI:1750813895
Name:HARRIS, SAMUEL (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 W 68TH ST
Mailing Address - Street 2:STE 202
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1801
Mailing Address - Country:US
Mailing Address - Phone:305-364-2107
Mailing Address - Fax:305-822-8347
Practice Address - Street 1:12651 W SUNRISE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-0906
Practice Address - Country:US
Practice Address - Phone:954-838-8801
Practice Address - Fax:954-838-8807
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS15623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program