Provider Demographics
NPI:1912969007
Name:HARRIS, DAVID W (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
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 1:1803 N ESTRADA
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-4017
Mailing Address - Country:US
Mailing Address - Phone:480-854-3707
Mailing Address - Fax:480-854-3707
Practice Address - Street 1:1803 N ESTRADA
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-4017
Practice Address - Country:US
Practice Address - Phone:480-854-3707
Practice Address - Fax:480-854-3707
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2011-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25099302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01172162Medicaid
CO3902-1Medicare ID - Type Unspecified
CO01172162Medicaid