Provider Demographics
NPI:1174553556
Name:HARRIS, BRYAN (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
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 1:6102 82ND ST STE 15
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-0802
Mailing Address - Country:US
Mailing Address - Phone:806-749-7933
Mailing Address - Fax:806-749-6117
Practice Address - Street 1:3715 21ST ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1219
Practice Address - Country:US
Practice Address - Phone:806-795-0610
Practice Address - Fax:806-795-0602
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7297207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046853001Medicaid
TX88951JMedicare ID - Type Unspecified
TX046853001Medicaid
070012872Medicare PIN
TXCP0061Medicare PIN