Healthcare Provider Details

I. General information

NPI: 1053341446
Provider Name (Legal Business Name): MICHAEL I HARRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 12/13/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 SAN MARIN DR
NOVATO CA
94945-1100
US

IV. Provider business mailing address

97 SAN MARIN DR
NOVATO CA
94945-1100
US

V. Phone/Fax

Practice location:
  • Phone: 415-899-7414
  • Fax: 415-899-7612
Mailing address:
  • Phone: 415-899-7414
  • Fax: 415-899-7612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG58482
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: