Provider Demographics
NPI:1487639050
Name:HARRIS, JESSE D (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:D
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 1:4845 KNIGHTSBRIDGE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-2463
Mailing Address - Country:US
Mailing Address - Phone:614-538-1249
Mailing Address - Fax:614-538-1926
Practice Address - Street 1:4845 KNIGHTSBRIDGE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-2463
Practice Address - Country:US
Practice Address - Phone:614-538-1249
Practice Address - Fax:614-538-1926
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-4198207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0693441Medicaid
OH0693441Medicaid
OHA17258Medicare UPIN