MEDICARE: JACK RICHARD HARRIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician	G1425	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	569909ZPF	OTHER	TX	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467445452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK RICHARD HARRIS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 603725
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-3725
Country	:	US
Telephone Number	:	828-575-2625
Fax Number	:	828-350-2174

Provider Business Practice Location Address
First Line	:	1128 MEDICAL DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-2109
Country	:	US
Telephone Number	:	903-593-8273
Fax Number	:	903-595-0204

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	10/31/2023

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