Provider Demographics
NPI:1053356535
Name:HARLESS, KEITH W (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:HARLESS
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:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-706-7715
Mailing Address - Fax:541-598-3492
Practice Address - Street 1:2275 NE DOCTORS DR
Practice Address - Street 2:SUITE 5
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6324
Practice Address - Country:US
Practice Address - Phone:541-706-7715
Practice Address - Fax:541-598-3492
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08626174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR290005326OtherRAILROAD
OR234351Medicaid
OR029WCGMFAMedicare ID - Type Unspecified
OR290005326OtherRAILROAD