Healthcare Provider Details

I. General information

NPI: 1790825842
Provider Name (Legal Business Name): MARK J HARRIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 E. OVERLAND RD.
MERIDIAN ID
83642
US

IV. Provider business mailing address

600 W ROBBINS RD STE 300
BOISE ID
83702-4568
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-1333
  • Fax: 208-489-4015
Mailing address:
  • Phone: 208-884-1333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberM9811
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: