Basic Information
| Provider Information | |||||||||
| NPI: | 1205179306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 CLARK RD | ||||||||
| Address2: | STE H1 | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342332366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419261600 | ||||||||
| FaxNumber: | 9419261166 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 CLARK RD | ||||||||
| Address2: | STE H1 | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342332366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419261600 | ||||||||
| FaxNumber: | 9419261166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2013 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OS15448 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.