Healthcare Provider Details

I. General information

NPI: 1982679825
Provider Name (Legal Business Name): MARK WILLIAM HARRIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

956 INTERNATIONAL PKWY STE 1580
LAKE MARY FL
32746-5219
US

IV. Provider business mailing address

1876 PIEDMONT PL
LAKE MARY FL
32746-7609
US

V. Phone/Fax

Practice location:
  • Phone: 407-706-1420
  • Fax: 407-705-3062
Mailing address:
  • Phone: 407-706-1420
  • Fax: 407-705-3062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCH0005746
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: