Provider Demographics
NPI:1083870455
Name:HARKLESS, JOHN MICHAEL (DO)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:HARKLESS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:340 PEPPERS FERRY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2056
Mailing Address - Country:US
Mailing Address - Phone:276-227-0200
Mailing Address - Fax:276-227-0202
Practice Address - Street 1:1040 HOLSTON RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-4107
Practice Address - Country:US
Practice Address - Phone:276-227-0200
Practice Address - Fax:276-227-0202
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-014404207Q00000X
VA0102202346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1083870455Medicaid
VA1083870455Medicaid