Provider Demographics
NPI:1992828354
Name:HARRELL, JON FREDRIC
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:FREDRIC
Last Name:HARRELL
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 1:2770 OAKBROOK LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33332-3407
Mailing Address - Country:US
Mailing Address - Phone:305-807-6731
Mailing Address - Fax:
Practice Address - Street 1:2133 N COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3238
Practice Address - Country:US
Practice Address - Phone:954-384-9692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 9033208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE 97052Medicare UPIN