Provider Demographics
NPI:1356648703
Name:HARRIS, JOHN WILLISTON (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLISTON
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 ARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1130
Mailing Address - Country:US
Mailing Address - Phone:818-500-0935
Mailing Address - Fax:818-500-0728
Practice Address - Street 1:435 ARDEN AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4018
Practice Address - Country:US
Practice Address - Phone:818-500-0935
Practice Address - Fax:818-500-0728
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA137473207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0007180Medicaid