Provider Demographics
NPI:1649252388
Name:HARLEY, JOHN W (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:HARLEY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:101 MARILYN AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4800
Mailing Address - Country:US
Mailing Address - Phone:574-533-2769
Mailing Address - Fax:574-534-6822
Practice Address - Street 1:101 MARILYN AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4800
Practice Address - Country:US
Practice Address - Phone:574-533-2769
Practice Address - Fax:574-534-6822
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2008-01-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN316902086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN208030AMedicare PIN
C24669Medicare UPIN