Provider Demographics
NPI:1730188269
Name:HARRIS, ROGER STANLEY (DO)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:STANLEY
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 1:39880 VAN DYKE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-4670
Mailing Address - Country:US
Mailing Address - Phone:586-264-7930
Mailing Address - Fax:586-264-7931
Practice Address - Street 1:39880 VAN DYKE AVE STE 202
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-4670
Practice Address - Country:US
Practice Address - Phone:586-264-7930
Practice Address - Fax:586-264-7931
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1371362Medicaid
MI1371353Medicaid
MI5500052Medicare ID - Type Unspecified
MI1371362Medicaid