Provider Demographics
NPI:1417448507
Name:HARRIS, ADON (MD)
Entity type:Individual
Prefix:
First Name:ADON
Middle Name:
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 1:4500 CASS AVE APT 913
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1286
Mailing Address - Country:US
Mailing Address - Phone:316-209-1654
Mailing Address - Fax:
Practice Address - Street 1:2016 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2655
Practice Address - Country:US
Practice Address - Phone:660-562-7999
Practice Address - Fax:660-562-7996
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024032663208600000X
MI4301115278208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301115278Medicaid
MI5315092623Medicaid