Provider Demographics
NPI:1982679825
Name:HARRIS, MARK WILLIAM (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1876 PIEDMONT PL
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7609
Mailing Address - Country:US
Mailing Address - Phone:407-706-1420
Mailing Address - Fax:407-705-3062
Practice Address - Street 1:956 INTERNATIONAL PKWY STE 1580
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5219
Practice Address - Country:US
Practice Address - Phone:407-706-1420
Practice Address - Fax:407-705-3062
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005746111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6511Medicare ID - Type Unspecified
FLT87702Medicare UPIN