Provider Demographics
NPI:1285607614
Name:HARRIS, GWEN N (MD)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:N
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E SUNRISE HWY
Mailing Address - Street 2:208
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2598
Mailing Address - Country:US
Mailing Address - Phone:631-225-7200
Mailing Address - Fax:631-930-9451
Practice Address - Street 1:519 E 72ND ST
Practice Address - Street 2:STE 103
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4028
Practice Address - Country:US
Practice Address - Phone:212-288-1575
Practice Address - Fax:212-288-7616
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170980174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01438146Medicaid
NY01438146Medicaid
NYF25448Medicare UPIN