Provider Demographics
NPI:1710040399
Name:HARRISON, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HARRISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UCONN MEDICAL GROUP
Mailing Address - Street 2:263 FARMINGTON AVE
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-0001
Mailing Address - Country:US
Mailing Address - Phone:860-679-2100
Mailing Address - Fax:860-679-4815
Practice Address - Street 1:UCONN MEDICAL GROUP
Practice Address - Street 2:263 FARMINGTON AVE
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-2100
Practice Address - Fax:860-679-4815
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA70045207RH0000X
CT054844207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8089302Medicaid
NJ034187Medicare ID - Type Unspecified
NJ8089302Medicaid