Provider Demographics
NPI:1194731257
Name:HARRIS, DAVID DWAYNE SR (PT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:DWAYNE
Last Name:HARRIS
Suffix:SR
Gender:M
Credentials:PT
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-3251
Practice Address - Street 1:10636 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-1969
Practice Address - Country:US
Practice Address - Phone:313-862-1340
Practice Address - Fax:313-862-1329
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002996225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6211071Medicare PIN