Basic Information
| Provider Information | |||||||||
| NPI: | 1912974288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | BAKER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 863640 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328863640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862747800 | ||||||||
| FaxNumber: | 3862747801 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 713 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043964369 | ||||||||
| FaxNumber: | 9043460864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2006 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME38728 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | ME38728 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 042178200 | 05 | FL | MEDICAID | 10985 | 01 | FL | BCBS | OTHER | 000930256B | 05 | GA | MEDICAID |