Healthcare Provider Details

I. General information

NPI: 1487074845
Provider Name (Legal Business Name): HIAWATHA HARRIS MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 BROADWAY SUITE-500
OAKLAND CA
94612-2141
US

IV. Provider business mailing address

5674 STONERIDGE DR SUITE-207
PLEASANTON CA
94588-8500
US

V. Phone/Fax

Practice location:
  • Phone: 510-273-4200
  • Fax:
Mailing address:
  • Phone: 925-520-0005
  • Fax: 925-520-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: CEDRIC HURSKIN
Title or Position: C.O.O
Credential:
Phone: 925-520-0005