Provider Demographics
NPI:1376563551
Name:HARRIS, JONATHAN A (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
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 1:415 HOOPER RD
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-3698
Mailing Address - Country:US
Mailing Address - Phone:607-754-3863
Mailing Address - Fax:607-754-5697
Practice Address - Street 1:415 HOOPER RD
Practice Address - Street 2:ENDWELL FAMILY PHYSICIANS LLP
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-3698
Practice Address - Country:US
Practice Address - Phone:607-754-3863
Practice Address - Fax:607-754-5697
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00557617Medicaid
10031687OtherCDPHP
NY0024397OtherCHAMPUS
3480OtherBLUEPOINT
58141OtherGHI HMO
3480OtherHMO BLUE
3480OtherBSCNY
4210330OtherAETNA
9684882OtherGHI
320946OtherMVP
3480OtherEMPIRE BS
3480OtherEXCELLUS
320946OtherMVP SELECT
878442OtherAETNA HMO
9684882OtherGHI
3480OtherEMPIRE BS