Healthcare Provider Details

I. General information

NPI: 1154359966
Provider Name (Legal Business Name): GARY STUART HARRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 10/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 IOWA AVE SUITE 280
RIVERSIDE CA
92507-2430
US

IV. Provider business mailing address

3651 LAKETREE DR
FALLBROOK CA
92028-9404
US

V. Phone/Fax

Practice location:
  • Phone: 951-786-0801
  • Fax: 951-786-0460
Mailing address:
  • Phone: 760-723-2676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG67633
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: