Provider Demographics
NPI:1447203666
Name:HEATH, HARLEY WILLIS (MD)
Entity Type:Individual
Prefix:
First Name:HARLEY
Middle Name:WILLIS
Last Name:HEATH
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 1:240 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4411
Mailing Address - Country:US
Mailing Address - Phone:603-569-7620
Mailing Address - Fax:603-569-7619
Practice Address - Street 1:240 S MAIN ST
Practice Address - Street 2:MEDICAL ARTS BLDG STE C
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894
Practice Address - Country:US
Practice Address - Phone:603-569-7620
Practice Address - Fax:603-569-7619
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH10485208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30011693Medicaid
E72414Medicare UPIN