Provider Demographics
NPI:1801901376
Name:FENDER, HARRIS ROBERTS JR (MD)
Entity type:Individual
Prefix:MR
First Name:HARRIS
Middle Name:ROBERTS
Last Name:FENDER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:H
Other - Middle Name:R
Other - Last Name:FENDER
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1015 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-597-9361
Mailing Address - Fax:903-597-6264
Practice Address - Street 1:1015 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-597-9361
Practice Address - Fax:903-597-6264
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9437208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX03249070Medicaid
TX032490701Medicaid
TX03249070Medicaid
TXB22681Medicare UPIN
TXCG73Medicare PIN