Basic Information
| Provider Information | |||||||||
| NPI: | 1326021882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2422 20TH ST SW | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584016201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Practice Location | |||||||||
| Address1: | 2422 20TH ST SW | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584016201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 10/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 008 | ND | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 2740001 | 01 | MEDICA | OTHER | 480012093 | 01 | MEDICARE RR PIN | OTHER | 11842 | 01 | ND | ND BLUE SHIELD | OTHER | HP20791 | 01 | HEALTH PARTNERS | OTHER | 13469 | 05 | ND | MEDICAID | 449161007917 | 01 | PREFERRED ONE | OTHER |