Healthcare Provider Details

I. General information

NPI: 1174591879
Provider Name (Legal Business Name): RAYMOND MARTIN HARRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 5TH STREET
BROOKINGS OR
97415
US

IV. Provider business mailing address

500 5TH ST
BROOKINGS OR
97415-9702
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-2000
  • Fax: 541-412-2081
Mailing address:
  • Phone: 541-412-2000
  • Fax: 541-412-2081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD167743
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: