Provider Demographics
NPI:1124290606
Name:CALEB H HARRIS MD FACS
Entity type:Organization
Organization Name:CALEB H HARRIS MD FACS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-762-6676
Mailing Address - Street 1:121 PATTON DR
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2030
Mailing Address - Country:US
Mailing Address - Phone:580-762-6676
Mailing Address - Fax:
Practice Address - Street 1:121 PATTON DR
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2030
Practice Address - Country:US
Practice Address - Phone:580-762-6676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23713208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK452193157-001OtherBLUE CROSS BLUE SHIELD OF OKLAHOMA
OK100144020BMedicaid
OK452193157-001OtherBLUE CROSS BLUE SHIELD OF OKLAHOMA