Provider Demographics
NPI:1679596985
Name:JOHN B HARRIS MD PA
Entity type:Organization
Organization Name:JOHN B HARRIS MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-274-1834
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-0790
Mailing Address - Country:US
Mailing Address - Phone:904-274-1834
Mailing Address - Fax:
Practice Address - Street 1:151 SAWGRASS CORNERS DR STE 102
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3554
Practice Address - Country:US
Practice Address - Phone:904-274-1834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08387OtherBLUE CROSS
FL08387Medicare ID - Type Unspecified