Healthcare Provider Details

I. General information

NPI: 1538164108
Provider Name (Legal Business Name): CAMILLE ELIZABETH HARRIS DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS CAMILLE ELIZABETH CLARK

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 E USTICK RD
CALDWELL ID
83605
US

IV. Provider business mailing address

1105 E USTICK RD
CALDWELL ID
83605-6306
US

V. Phone/Fax

Practice location:
  • Phone: 208-463-7732
  • Fax: 541-889-4736
Mailing address:
  • Phone: 208-402-6587
  • Fax: 208-402-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDP00359
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: