1538164108 NPI number — DR. CAMILLE ELIZABETH HARRIS DPM

Table of content: DR. CAMILLE ELIZABETH HARRIS DPM (NPI 1538164108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538164108 NPI number — DR. CAMILLE ELIZABETH HARRIS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
CAMILLE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
CAMILLE
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538164108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1105 E USTICK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALDWELL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83605-6306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-402-6587
Provider Business Mailing Address Fax Number:
208-402-6578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1105 E USTICK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-463-7732
Provider Business Practice Location Address Fax Number:
541-889-4736
Provider Enumeration Date:
06/20/2005

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: 213E00000X , with the licence number:  DP00359 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807150700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00251554 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 861141948 . This is a "TAX ID" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 023111 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4540570001 . This is a "MEDICARE DMERC" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: P00251554 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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