Provider Demographics
NPI:1245675016
Name:HARRIS, BRIAN A (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
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 1:83 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1106
Mailing Address - Country:US
Mailing Address - Phone:321-841-9340
Mailing Address - Fax:321-841-9344
Practice Address - Street 1:83 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1106
Practice Address - Country:US
Practice Address - Phone:321-841-9340
Practice Address - Fax:321-841-9344
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1411332080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103150000Medicaid