Provider Demographics
NPI:1609899178
Name:HARRIS, JOHN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
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 1:401 SAN JUAN DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2822
Mailing Address - Country:US
Mailing Address - Phone:904-285-8838
Mailing Address - Fax:904-285-4011
Practice Address - Street 1:151 SAWGRASS CORNERS DR STE 102
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3554
Practice Address - Country:US
Practice Address - Phone:904-274-1834
Practice Address - Fax:904-373-5840
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME544192086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08387OtherBLUE CROSS
FL08387Medicare ID - Type Unspecified
FL08387OtherBLUE CROSS