Healthcare Provider Details

I. General information

NPI: 1477665446
Provider Name (Legal Business Name): THOMAS E. HARRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 N SALEM RD SUITE 6
FAYETTEVILLE AR
72704-8807
US

IV. Provider business mailing address

PO BOX 1523
FAYETTEVILLE AR
72702-1523
US

V. Phone/Fax

Practice location:
  • Phone: 479-442-0006
  • Fax: 479-442-3038
Mailing address:
  • Phone: 479-571-6038
  • Fax: 479-582-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number107345
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC-6832
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: