Healthcare Provider Details

I. General information

NPI: 1124011689
Provider Name (Legal Business Name): ETHAN GEOFFREY HARRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 E MONTE VISTA AVE
VACAVILLE CA
95688-3009
US

IV. Provider business mailing address

PO BOX 999 13437 ANTELOPE TRAIL
OREGON HOUSE CA
95962-0999
US

V. Phone/Fax

Practice location:
  • Phone: 707-469-4610
  • Fax:
Mailing address:
  • Phone: 530-692-0802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG18727
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: