Provider Demographics
NPI:1477551216
Name:HARMON, MICHAEL W (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:HARMON
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:BLUE LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95525-0368
Mailing Address - Country:US
Mailing Address - Phone:707-668-5743
Mailing Address - Fax:707-668-5873
Practice Address - Street 1:2700 DOLBEER ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4736
Practice Address - Country:US
Practice Address - Phone:707-269-4229
Practice Address - Fax:707-269-3849
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG712192085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG71219OtherLICENSE
CAGR0088900Medicaid
CAG71219OtherLICENSE
ZZZ39052ZMedicare ID - Type Unspecified