Provider Demographics
NPI:1326585217
Name:HARRISON, GARRETT DANIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:DANIEL
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W LOSEY ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225-5250
Mailing Address - Country:US
Mailing Address - Phone:618-256-9355
Mailing Address - Fax:
Practice Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1284
Practice Address - Country:US
Practice Address - Phone:618-233-5480
Practice Address - Fax:618-222-4792
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205368207V00000X
390200000X
IL036159184207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program