Provider Demographics
NPI:1972510626
Name:HARRIS, JONATHAN SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:SAMUEL
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 1:1 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-1018
Mailing Address - Country:US
Mailing Address - Phone:914-934-2473
Mailing Address - Fax:
Practice Address - Street 1:1545 UNIONPORT RD
Practice Address - Street 2:PARK SOUTH MEDICAL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462
Practice Address - Country:US
Practice Address - Phone:718-892-2201
Practice Address - Fax:718-828-9663
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215283207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY075ADWT411Medicare PIN
NYH69328Medicare UPIN