Healthcare Provider Details

I. General information

NPI: 1881188563
Provider Name (Legal Business Name): ETHAN DANIEL HARRIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 05/17/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 482
FPO, AP CA
96362
US

IV. Provider business mailing address

200 MERCY CIR
OCEANSIDE CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 315-646-7037
  • Fax:
Mailing address:
  • Phone: 760-725-1288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number68267
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: