1154359966 NPI number — DR. GARY STUART HARRIS M.D.

Table of content: DR. GARY STUART HARRIS M.D. (NPI 1154359966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154359966 NPI number — DR. GARY STUART HARRIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
GARY
Provider Middle Name:
STUART
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154359966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3651 LAKETREE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALLBROOK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92028-9404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-723-2676
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1770 IOWA AVE
Provider Second Line Business Practice Location Address:
SUITE 280
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92507-2430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-786-0801
Provider Business Practice Location Address Fax Number:
951-786-0460
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  G67633 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G67633 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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