Provider Demographics
NPI:1386718500
Name:HARRIS, MARK STEVEN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 UPPER PLAIN
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05033
Mailing Address - Country:US
Mailing Address - Phone:802-222-4722
Mailing Address - Fax:802-222-4709
Practice Address - Street 1:1123 SOUTH RD
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:VT
Practice Address - Zip Code:05033-8803
Practice Address - Country:US
Practice Address - Phone:802-272-2674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006039208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004689Medicaid
NH99004689Medicaid
030367834OtherTAX ID
NH99004689Medicaid
VTVT4689Medicare PIN
474111350OtherTIN