Provider Demographics
NPI:1760555379
Name:HARRISON, THEODORE JOEL (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOEL
Last Name:HARRISON
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 1:2 FIFTH AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011
Mailing Address - Country:US
Mailing Address - Phone:212-254-2020
Mailing Address - Fax:212-673-3236
Practice Address - Street 1:2 FIFTH AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:212-254-2020
Practice Address - Fax:212-673-3236
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152876207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C12255Medicare UPIN