Provider Demographics
NPI:1396789939
Name:HARRIS, GARY DALE (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:DALE
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 1:15435 W 134TH PL
Mailing Address - Street 2:STE #101
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062
Mailing Address - Country:US
Mailing Address - Phone:913-780-0030
Mailing Address - Fax:913-782-2924
Practice Address - Street 1:15435 W 134TH PL
Practice Address - Street 2:STE #101
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062
Practice Address - Country:US
Practice Address - Phone:913-780-0030
Practice Address - Fax:913-782-2924
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0417846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS10014510AMedicaid
KS10014510AMedicaid
E22776Medicare UPIN