Basic Information
Provider Information | |||||||||
NPI: | 1629229364 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRIS | ||||||||
FirstName: | CHE | ||||||||
MiddleName: | MATTHEW | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 314 PALMSPRING DR | ||||||||
Address2: |   | ||||||||
City: | GAITHERSBURG | ||||||||
State: | MD | ||||||||
PostalCode: | 208782941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2404613873 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2041 GEORGIA AVENUE | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON D.C | ||||||||
State: | DC | ||||||||
PostalCode: | 20060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2028656100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2008 | ||||||||
LastUpdateDate: | 09/25/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 111111111 | DC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | D68924 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 022548700 | 05 | MD |   | MEDICAID |