Provider Demographics
NPI:1588694988
Name:HARRIS, WESLEY W JR (MD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:W
Last Name:HARRIS
Suffix:JR
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 1:103 WILLOW TREE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIANVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35759-5100
Mailing Address - Country:US
Mailing Address - Phone:706-331-0365
Mailing Address - Fax:301-235-1522
Practice Address - Street 1:101 SIVLEY RD SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4470
Practice Address - Country:US
Practice Address - Phone:256-265-9889
Practice Address - Fax:256-265-9910
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA640034703AMedicaid
GA93BFBMDMedicare ID - Type Unspecified
GA640034703AMedicaid