=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639282452
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEOFFREY R HARRIS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2006
-----------------------------------------------------
Last Update Date | 03/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4428 VIA JUANITA
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-6819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-262-2012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4428 VIA JUANITA
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-6819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-262-2012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | A89734
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A89734
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------