Provider Demographics
NPI:1962548016
Name:HARRIS, ERIC BRENT (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:BRENT
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 1:34800 BOB WILSON DR
Mailing Address - Street 2:DEPARTMENT OF ORTHOPAEDICS
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:619-532-8427
Mailing Address - Fax:619-532-8467
Practice Address - Street 1:1909 VISTA DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5530
Practice Address - Country:US
Practice Address - Phone:307-745-8851
Practice Address - Fax:307-742-0961
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11071A207X00000X
PAMD432120207X00000X
IN01053569A207X00000X
CAA114325207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106251400Medicaid
PA3317054000OtherIBC PA
7558911OtherAETNA