Healthcare Provider Details

I. General information

NPI: 1831277029
Provider Name (Legal Business Name): BILL DOUGLAS HARRIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 HOUSE AVE STE 502
CHEYENNE WY
82001-3179
US

IV. Provider business mailing address

2301 HOUSE AVE STE 502
CHEYENNE WY
82001-3179
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-4131
  • Fax: 307-635-4134
Mailing address:
  • Phone: 307-635-4131
  • Fax: 307-635-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number7170A
License Number StateWY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierP00143425
Identifier TypeOTHER
Identifier StateWY
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier120815200
Identifier TypeMEDICAID
Identifier StateWY
Identifier Issuer
# 3
Identifier313039
Identifier TypeOTHER
Identifier StateWY
Identifier IssuerBCBS OF WYOMING

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: