Healthcare Provider Details

I. General information

NPI: 1063617934
Provider Name (Legal Business Name): JUSTIN D HARRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 TECHNOLOGY DR
IRVINE CA
92618-2302
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 949-923-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA123173
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: