1972501633 NPI number — DR. WALTER ALAN HARMON MD

Table of content: DR. WALTER ALAN HARMON MD (NPI 1972501633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972501633 NPI number — DR. WALTER ALAN HARMON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARMON
Provider First Name:
WALTER
Provider Middle Name:
ALAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972501633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4800 BELFORT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-6004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-398-3262
Provider Business Mailing Address Fax Number:
904-265-4807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 SHIRCLIFF WAY
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32204-4757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-381-9379
Provider Business Practice Location Address Fax Number:
904-381-9314
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  ME38382 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 065379900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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