Basic Information
| Provider Information | |||||||||
| NPI: | 1750813895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | SAMUEL | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 W 68TH ST | ||||||||
| Address2: | STE 202 | ||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330161801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053642107 | ||||||||
| FaxNumber: | 3058228347 | ||||||||
| Practice Location | |||||||||
| Address1: | 12651 W SUNRISE BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333230906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548388801 | ||||||||
| FaxNumber: | 9548388807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2017 | ||||||||
| LastUpdateDate: | 06/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | OS15623 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.