Basic Information
| Provider Information | |||||||||
| NPI: | 1720191919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARMON | ||||||||
| FirstName: | DOUGLAS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 ATLANTIC BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322118768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666385931 | ||||||||
| FaxNumber: | 9048051456 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454054720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005141494 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 01/18/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34007506 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2332121 | 05 | OH | MEDICAID | 000000032022 | 01 | OH | BCBS | OTHER | 000000291736 | 01 | OH | BCBS | OTHER | P00115646 | 01 | RR MCR | OTHER |