Provider Demographics
NPI:1770744070
Name:HARRIS, BLAYNE M (MD)
Entity type:Individual
Prefix:
First Name:BLAYNE
Middle Name:M
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 1:1600 W 38TH ST
Mailing Address - Street 2:SUITE 421
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6400
Mailing Address - Country:US
Mailing Address - Phone:512-407-9440
Mailing Address - Fax:512-407-9448
Practice Address - Street 1:1600 W 38TH ST
Practice Address - Street 2:SUITE 421
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6400
Practice Address - Country:US
Practice Address - Phone:512-407-9440
Practice Address - Fax:512-407-9448
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2014-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4470972084P0800X
IN01071624A2084P0800X
TXQ07632084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry