Provider Demographics
NPI:1649267634
Name:HARRIS, JEFFREY LYNN (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LYNN
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 SUNCREST DR
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-1136
Mailing Address - Country:US
Mailing Address - Phone:810-664-4870
Mailing Address - Fax:810-664-0921
Practice Address - Street 1:1031 SUNCREST DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1136
Practice Address - Country:US
Practice Address - Phone:810-664-4870
Practice Address - Fax:810-664-0921
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5105007337207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4909952Medicaid
E37385Medicare UPIN
MIP33590005Medicare ID - Type UnspecifiedCCEM MEDICARE ID
MI4909952Medicaid