Provider Demographics
NPI:1528056850
Name:HARRIS, PENNY B (MD)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:B
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2160 APPIAN WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2524
Mailing Address - Country:US
Mailing Address - Phone:510-724-9110
Mailing Address - Fax:916-239-3602
Practice Address - Street 1:1332 PARK ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4545
Practice Address - Country:US
Practice Address - Phone:510-523-3417
Practice Address - Fax:916-239-3614
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG26304208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC04155Medicare UPIN
CA00G263041Medicare ID - Type Unspecified