Provider Demographics
NPI:1023166444
Name:HARRIS, CANAAN LAVELLE (MD)
Entity type:Individual
Prefix:
First Name:CANAAN
Middle Name:LAVELLE
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 1:1315 ST JOSEPH PKWY STE 1001
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-8231
Mailing Address - Country:US
Mailing Address - Phone:713-658-1900
Mailing Address - Fax:713-658-1971
Practice Address - Street 1:1315 ST JOSEPH PKWY STE 1001
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8231
Practice Address - Country:US
Practice Address - Phone:713-658-1900
Practice Address - Fax:713-658-1971
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
TXG1424174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX760356749OtherTAX IDENTIFICATION NUMBER
TX760356749Medicaid
TX035694101Medicaid