Provider Demographics
NPI:1538164108
Name:HARRIS, CAMILLE ELIZABETH (DPM)
Entity type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:ELIZABETH
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:MISS
Other - First Name:CAMILLE
Other - Middle Name:ELIZABETH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1105 E USTICK RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6306
Mailing Address - Country:US
Mailing Address - Phone:208-402-6587
Mailing Address - Fax:208-402-6578
Practice Address - Street 1:1105 E USTICK RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-463-7732
Practice Address - Fax:541-889-4736
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00359213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807150700Medicaid
ORP00251554OtherRAILROAD MEDICARE
OR861141948OtherTAX ID
OR023111Medicaid
OR4540570001OtherMEDICARE DMERC
IDP00251554OtherRAILROAD MEDICARE
ID807150700Medicaid
ORR132078Medicare PIN
ORP00251554OtherRAILROAD MEDICARE